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Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
cases it progresses with development of a macular or maculopapular rash, sometimes complicated by lung and/or central nervous system involvement and, at the end of the clinical spectrum, septic shock with multiorgan failure. Case report: 51-year-old male farmer, with history of chronic alcoholism, admitted by fever, disorientation, nausea and vomiting, whose clinical condition rapidly deteriorated, with hemoptysis, severe hypoxemia and progression to septic shock, with the need for institution of respiratory and hemodynamic support. He presented a disseminated macular rash, which, together with the epidemiologic data, raised the suspicion of rickettsial infection, even though an inoculation eschar was absent. Accordingly, empirical treatment with intravenous doxycycline was started. Renal failure ensued, dictating the implementation of renal replacement techniques. Acute hepatic failure, consumption coagulopathy and anemia imposed transfusion of several units of blood derivatives. Lumbar puncture was performed, without any relevant findings. Hypoperfusion of the inferior limbs and hands developed, evolving to cutaneous and digital necrosis. Although surgical debridement and coverage with growth factor-impregnated amniotic membrane was performed, lack of viability of muscle tissue was later documented, leading to amputation. Imagiologic study revealed moderate hepato-splenomegaly with peripheral infarcted areas. Several episodes of abundant hematochezia occurred, in relation to exuberant terminal ileitis, but hystopathological examination was not clarifying. In spite of the clinical severity, the patient evolved favourably, with improvement of the abdominal lesions and regeneration of the ileal mucosa. Although the initial serologic test for Rickettsia conorii was weakly positive, seroconversion was documented at the third week and rickettsial DNA was found in the edges of the necrotic lesions of the limbs. Conclusion: Pathogenesis of Mediterranean spotted fever is primarily based on the increased vascular permeability secondary to infection of endothelial cells, with resultant hypovolemia and ischemia, aggravated by hemorrhagic and vaso-occlusive phenomena. Prognosis is naturally worse in settings of immunodepression like chronic alcoholism, with a high mortality rate, surviving being rare in cases of severe multiorgan involvement like the one described. Initial manifestations are non-specific and seroconversion only detectable beyond the tenth day after the beginning of symptoms; immediate institution of antibiotic therapy is therefore paramount once clinical and epidemiological suspicion is raised, even in face of a negative serologic result.
P0736 PSEUDOMONAS STUTZERI CAUSING LATE MECHANICAL PROSTHETIC VALVE ENDOCARDITIS
Jenny Gradinayna, Bruno Oliveira, Anabela Oliveira. Hospital Santa Maria Late prosthetic valve endocarditis (LPVE) is an infrequent, though serious, complication of cardiac valve replacement, affecting biological prostheses more often than mechanical ones. Gram negative bacilli endocarditis are rare and Pseudomonas aeruginosa is the most common pathogen in this group. Pseudomonas stutzeri lives as a saprophyte in man and is ordinarily found in soil and water. It has been implicated in rare cases of wound infections, osteomyelitis, otitis media and blepharitis. We report the case of a 69 year old woman who, two month prior, had underwent replacement of aortic valve with a mechanical prosthesis. She presented with fever of unknown origin and the workup established the diagnosis of LPVE, meeting Duke’s criteria. Three separate hemocultures isolated Pseudomonas stutzeri and, with targeted antibiotherapy, complete remission of symptoms was observed. We reviewed the literature and found only 7 cases reporting infectious endocarditis due to Pseudomonas stutzeri. Despite extensive search, no previous description of mechanical prosthetic valve endocarditis caused by this pathogen was found. We believe this to be the first reported case. Keywords Late prosthetic valve endocarditis Pseudomonas stutzeri mechanical Duke’s criteria infectious
P0737 TYPHOID FEVER – WHAT IS THE CLINICAL VALUE OF THE WIDAL TEST?
Célia Henriques, Ana Soares, Bruno Grima, Nuno Riso. Curry Cabral Hospital The Typhoid Fever is a multysistemic disease potentially fatal, caused primarily by the Salmonella typhi witch has kept endemic in developing countries. In Portugal, with the improvement of the basic sanitary conditions and with a use of an efficient antibiotic therapy, the incidence of Typhoid Fever has de-
creased drastically, been most of the detected cases originative from endemic regions. The authors present a case of a male 67 year old patient, with a history of total prostatectomy, with two month evolution, characterized by a maximum body temperature of 37.8°C, associated with shiver and a left fronto-temporal headache. The imagiological studies, excluded neoplasic and infectious endocarditis. The bacteriological studies with blood cultures, urine and stool cultures reveled negative. The Widal test came positive for the thyphic antigenic O in 1/160 and for the thypic antigenic H in 1/320. The immunological study, with antibody dosage, complements and immunoglobulins was negative. Although the infectious agent could not be isolated in the cultures, because of the persistence of the symptoms, the patient began antibiotherapy with azithomicin, with complete remission of symptoms. With the early use of antibiotic therapy, the typhoid fever is a disease typically limited by the risk of negligible mortality. However, when existing a late diagnose, the risk of serious complications is considerable. The diagnosis of typhoid fever becomes a challenge due to changed typical clinical pattern of the disease, mostly in the endemic areas. The Widal test is nowadays considered poorly effective for definitive diagnosis, becoming an important element in diagnosis guidance which should not, however, limit the complete etiological investigation.
P0738 UNUSUAL EVOLUTION OF TUBERCULOSIS-CASE REPORT
Rebelo Marta, Castellano Maria, Mota Joana, Silva Nuno, Vieira José, Moura José. Hospitais Da Universidade De Coimbra Tuberculosis is one important infectious disease plaguing the developed and developing countries worldwide. Has an high prevalence in high risk groups. Because has various forms of presentation, continues to be a clinical challenge. The cerebral tuberculomas are rare forms of neurotuberculosis and result from the hematogeneous dissemination of distant focus of infection by Mycobacterium tuberculosis. Aproximatly 1% of the patients with tuberculosis of central nervous system develops intracranial tuberculomas. The authors report a case of a 60 years old male, non-smoker, admitted in our Hospital with one month evolution of high fever, weight loss (15KG), anorexia and astenia. Laboratory data showed leucocytes - 3,8×103 /μl; ferritin - 1.734ng/ml, CRP - 1,8 mg/dl. Thoracic radiography revealed micronodular bilateral infiltrate. At the third day started with night predominance holocraneal headache and disequilibrium upon walking. Cephaloraquidian liquor (CRL) revealed a celularity - 111.0/mm3 with polymorphonuclears predominance, glucose 41mg/dl (40-70), proteins - 165 mg/dl (15.40) and cryptococcus negative. HIV and HBsAg were negative. Cranial Computerized Tomography (CT) revealed a nodular lesion (0,35 cm) with hipodense halo, but that did’t excluded the possibility of a tumor lesion. Magnetic ressonance showed right frontal sub-cortical lesions, but without mass effect, probable secondary lesions of a primary tumor. The toracic CT revealed a reticular-nodular pattern sugestive of Tuberculosis miliar. CRL BK culture was positive. Patient started therapeutic with Isoniazid, Rifampicin and Pirazinamid achieving a good clinical and radiologic response. Tuberculosis is a rare disease and in immunocompetent patients can have wide range of manifestations, which delays diagnosis and treatment. This case calls atention for the importance of an early diagnosis.
P0739 CEREBELLAR NOCARDIOSIS IN AN IMMUNOCOMPETENT PATIENT
Castellano Maria, Lourenço Nulita, Rebelo Marta, Serra Eduardo, Moura José, Moura José Alves. Hospitais Da Universidade De Coimbra Nocardiosis is a rare bacterial infection caused by aerobic, Gram positive bacteria, which belongs to the family Actinomycetes, gender Nocardia. Is considered an acute, subacute, or chronic suppurative infection caused by Nocardia. It has a pronounced tendency to remission and exacerbation. Infections are localized or disseminated. Localized cutaneous or lymphocutaneous infections usually occur after contamination of an abrasion, resulting in cutaneous or lymphocutaneous abscess Nocardiosis is an opportunistic infection in immunocompromised patients, though about 1/3 of all infected patients are immunocompetent. Can be transmitted not only by skin contact, but also by inhalation of spores. The systemic involvement occurs in 32% of cases and about 9% of patients with nocardiosis have involvement restricted to the central nervous system (CNS). The Nocardia is responsible for only 2% of brain abscesses diagnosed and is
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283 therefore considered a rare disorder. Brain abscess capsule is an highly characteristic lesion. The authors present a case of cerebellar and bulbar Nocardiosis in an immunocompetent patient. After admission the patient developed several complications namely Candidemia, urinary infection and respiratory arrest with the need of ventilatory support. Developed subsequent episodes of paroxistic symptomatic sinus bradycardia that required the placement of a permanent pacemaker, following of which was diagnosed micro-abscesses in the bulbar region. The patient maintain antibiotherapy and presents currently with a psychomotor delay. The authors also made a statistical survey of diagnosis of nocardiosis in the last 10 years in the Department of Infectious Diseases of our hospital. Were reported 3 cases during this period, two of which in immunocompromised patients (AIDS and corticotherapy) and one in a previously healthy patient.
P0740 CONTINUOUS INFUSION OF VANCOMICIN IN METHICILLIN-RESISTANT STAPHYLOCOCCUS INFECTION – EXPERIENCE OF AN INTENSIVE CARE UNIT
Ana Isabel Videira Gonçalves, Tiago Pereira, Raquel Nazareth, Isabel Rio Carvalho, Eduarda Carmo, Isabel Gaspar, Isabel Simões, José Luís Neves, Eduardo Monteiro. Unidade De Cuidados Intensivos Polivalente - Hospital Egas Moniz Introduction: Although intermittent intravenous administration of antibiotics is the standard clinical practice worldwide, there is renewed interest among clinicians and researchers in examining the benefits of continuous administration of antibiotics, since there is potential for further improvement of the outcome of patients treated with antibiotics for severe infections in most clinical settings. Vancomycin, the agent most commonly used against methicillinresistant Gram-positive cocci, has been used more frequently in recent years due to the rising occurrrence of infections caused by methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus epidermidis (MRSE).The effect of vancomicin is time-dependent. Giving it by continuous i.v. infusion maximizes the time during which the serum antibiotic concentration is effective but non-toxic.Monitoring serum concentrations can help reduce health care costs. Aims: The aim of this study was to examine retrospectively the patients treated with continuous infusion of vancomicin in methicillin-resistant Staphylococcus infection focused to the epidemiological parameters, like age, gender, the principal diagnosis, co morbid conditions, ICU lenght of stay, daily venous concentration of vancomicin and finally the outcome. Conclusion: Continuous infusion greatly improve the activity of vancomicin and it may prove useful against isolates with reduced susceptibility to the agent. In an era of gradually increasing resistance among most pathogens, the potential advantages of continuous intravenous administration of antibiotics should be further investigated.
P0741 THE KNOWLEDGE AND ATTITUDE OF GAZI UNIVERSITY NURSING COLLEGE STUDENTS ON BLOODBORNE DISEASE
Sevinç Kutlutürkan, Ülkü Görgülü, Hatice Fesci. Gazi University School of Nursing Introduction: Healthcare workers are at risk for many infectious diseases from the patients in their workplace and the diseases that may pass through the physical environment. The risk of transmission is also a very important problem for nursing students as a large part of their training is spent in clinical application in this environment. It is necessary to evaluate transmission-related factors to develop protective strategies against these diseases. Objective: This study was planned as a descriptive study to evaluate the knowledge and behavior related to blood borne disease of nursing students who will take their place in the healthcare field of our country in the future. Material and methods: A total of 239 students from the first to fourth years of the Gazi University Nursing College were included in this study. We obtained written consent from the institution and verbal consent from the students for the study. A survey form was used as the data collection instrument. The data were evaluated with the SPSS 11.0 software. Statistical evaluation was with averages, percentages. Result: We found that 5.9% of the participating students had natural immunity against hepatitis B and 82% had received hepatitis B vaccination while 12.1% had not completed the vaccination doses. The mean knowledge score of the participating students on blood borne disease was 16,25± 2.27. The mean knowledge level scores for the first, second and third years were 15,52±2,91,
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16,27±2.21, 16,62±1.95 and 16,50±1.89 respectively. The students feared transmission of disease when caring for a patient with blood borne disease at a rate of 79.5% while 32.6% felt that these patients should be cared for in separate institutions and 30.1% did not feel they could prevent the transmission of a virus causing blood borne disease. The students were found to use gloves (always 72%, sometimes 28%), masks (always 11.7%, sometimes 74.1%), double bags/special bags/closed boxes for virus-infected material and equipment (always 67.8%, sometimes 20.9%), disposable material (always 88.3%, sometimes 11.7) and washed their hands (always 95.8%, sometimes 4.2%) to protect themselves from blood borne disease. We determined that nursing students, and especially first year students, had inadequate information on blood borne disease. Conclusion: In light of these findings, we recommend providing student training with repeated seminars and conferenceson blood borne disease and preventive measures before each clinical procedure. We believe that this will prevent a negative reflection of the lack of student knowledge on this subject on clinical procedures and patient care. Key words: blood borne disease, nurse, protective strategies, nursing student
P0742 BRUCELLAR SPONDYLODISCITIS – A CASE REPORT WITH A THEURAPEUTIC CHALLENGE
Michele Costa, Miguel Serrano, Cristina Duarte, Nuno Bragança. Hospital Fernando Fonseca Brucellosis remains an important public health issue, requiring combined and prolonged antibiotic (AB) treatment. We present a case of a 43-year-old male admitted to our hospital with lumbar pain presenting one month earlier. The patient was an ovine and caprine breeder, and regular consumer of unpasteurized dairy products. On admission the patient presented normocytic normochromic anemia, elevated erythrocyte sedimentation rate and C-reactive protein, and positive Rose Bengal test (RBT). The lumbosacral computed tomography showed spondylodiscitis of L5-S1 with epidural compromise. The lumbosacral magnetic resonance imaging (LS-MRI) confirmed spondylodiscitis of L5-S1 with bone involvement, paravertebral abscess, and epidural abscess with compromise of L5-S2 nerve roots. The diagnosis of brucellar spondylodiscitis was placed, and AB therapy with doxycycline and rifampicin was initiated. LS-MRI at six months showed aggravation of prior lesions, and RBT was positive. Indication for surgical intervention was excluded, and triple AB therapy was initiated by associating ciprofloxacin to the current regimen. Two months later the LS-MRI showed improvement of lesions, but the RBT remained positive. Some adverse effects due to doxycycline and rifampicin were experienced; due to this, and because of favorable evolution after initiation of ciprofloxacin, the initial AB regimen was ceased, and monotherapy with ciprofloxacin was maintained. After six months the LS-MRI showed favorable evolution towards chronicity, without compression of meningoradicular structures, and the RBT was negative. Due to radiological improvement and remission of symptoms, AB therapy was halted and regular follow-up was maintained. Spondylodiscitis is one of the most prevalent and important clinical forms of osteoarticular involvement in brucellar infection. However, spinal cord compression due to brucellar epidural abscess is rare with few reported cases. This case is marked by its therapeutic challenge. Quinolone-containing regimens may be used for the management of brucellosis, in double or triple AB regimens. However, quinolones are not recommended as first-line therapy, neither as an option for monotherapy.
P0743 PYLEPHLEBITIS OF UNKNOWN ORIGIN – A CASE REPORT
Michele Costa, Cristina Duarte, Nuno Candeias, Tereza Cruz, Nuno Bragança. Hospital Fernando Fonseca Pylephlebitis, a septic thrombophlebitis of the portal vein, is a rare and life-threatening condition that usually occurs as a complication of infection in the region drained by the portal system or in the structures contiguous to the portal vein. We present a case of a diabetic 67-year-old man admitted with thrombophlebitis of the portal vein of unknown origin. On admission the patient presented fever, abdominal pain, asthenia, and anorexia. Laboratory analysis demonstrated leukocytosis, abnormal liver function tests, and elevated C-reactive protein. Doppler ultrasonography of the portal vein showed thrombosis of the portal vein with signs of portal hypertension. Studies