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P0768 COMPARATIVE STUDY OF TWO GROUPS OF PATIENTS WITH SEVERE SEPSIS, BEFORE AND AFTER IMPLANTATION OF
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Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
Results: Discharge at 32° day of Penicillin, resolution of amenorrhea, normal laboratory, abdomino-pelvic ultrasound with significant improvement. She was medicated with amoxicillin 1 g 8/8h po 6 months. Final diagnosis: Actinomycosis, co-infection by Bacteroides fragilis, Enterobacter faecium, Candida albicans and multifactorial anemia. Conclusions: The diagnosis of actinomycosis is very rare nowadays and it’s easily misdiagnosed as a cancer advanced disease. It has a good prognosis with proper diagnosis and medication. This extensive abdomino-pelvic form of actinomycosis occurred in a immunocompetent woman without intrauterine contraceptive device. Keywords: Actinomycosis
P0767 CASE REVIEW OF EMPIEMA NECESSITATIS
Silvia Vidal, Cristina Araguás, Xavi Pla, Pablo Villacé, Ester Oviedo, Gema Martinez. Medicina Interna, Corporació Sanitaria Parc Tauli. Sabadell (barcelona) Objectives: We reviewed all the cases of “Empiema Necessitatis” diagnosed in our hospital since 1996. We determine the features of comorbidity, treatment and patient’s evolution. We describe all the clinical, analytic, radiological, microbiological findings. Material and methods: Selection of 8 patients with a radiological diagnosis of Empiema Necessitatis. Retrospective review of all the medical histories. Collection of data in data base and descriptive analysis with statistic package SPSS v12. Results: (N=8).DEMOGRAPHICS: average age 72,8(39-84), sex (men 6 (75%)).COMORBIDITY: Smoking 25%(2), enol habit 25%(2), parental drug abusers (PDA) 1(12,5%), COPD 3(37,5%), history of TBC 5(62,5%). Previous pleural pathology 8(100%) of which 1 is for thoracotomy, 5 for pachypleuritis, 1 for deformities postTBC and 1 for asbestosys. Immunosuppressant 1 (12,5%) for HIV 1 (12,5%), none had neoplasm. Thoracic previous surgery 1 (12.5%), asbestos exposure 2 (25%). CLINIC: 4 patients had pain (50%), 4 fever (50%), 3 cough (not dry) (37,5%), 4 toxic syndrome (50%), 4 difficulty in breathing (50%), 5 were presenting thoracic mass (62,5%) and 1 respiratory insufficiency (12.5%). LABORATORY: Hb13,01g/dl (±1,5), Leukocytes 19690 10x6/L (±4399), neutrophils 7730 10x6/L (±4355), LDH 364U/L (±138), VSG 57,7mm1a h (±20,18), PCR 3,16mg/dL (±2,8), Cr 0,95mg/dl (±0,39), Albumen 34,6g/L (±4,6), Bilirrubin 0,6mg/dL (±0,3). ADA of the pleural liquid of 2 patients 69,3(±21). RADIOLOGY: In the simple radiology they presented: condensation 1 patient (12,5%), pleural effusion 3 (37,5%) and pleural widening 5(62.5%). In the evaluation by TC was observed: 100% (8) of the patients pleural effusion, 100% pleural affection and 62.5% (5) abscess of thoracic wall. MICROBIOLOGY: 2 exudate cultures +:1 Pseudomona (12,5%) and 1 Candida albicans (12,5%), 3 (32,5%) Lowenstein cultures were positive (none of them show a positive Ziehl Neelsen stain) and 2 patients did not have microbiological diagnosis. TREATMENT: 2 patients received antibiotic (25%), 3 Tuberculostatics (32,5%) and 1 antifungal treatment (12,5%). 2 needed a pleural drainage (25%) and 3 Surgery (32,5%). EVOLUTION: Resolution in 5 patients (62,5%), relapsed into 2 (25%) and 1 patient died for not related reason. Discussion: Some findings to stand out in our series:-description of one of the first cases of empiema necessitatis for candida albicans published-the fall rendibility diagnostic of the tint for bacilli resistant acid-alcohol in patients with positive Lowenstein culture,-the hight prevalence of precedent of pleural previous pathology (in 100% of the patients). Conclusions: Empiema necessitatis is a rare complication of a pleural Para pneumonic effusion not treated. The mycobacterium tuberculosis is the most frequent aetiology. The most relevant clinical feature is the presence of a thoracic mass. The utility of the TC and the PAAF in the diagnosis of this entity is widely demonstrated. We present an atypical case of fungi aetiology.
P0768 COMPARATIVE STUDY OF TWO GROUPS OF PATIENTS WITH SEVERE SEPSIS, BEFORE AND AFTER IMPLANTATION OF
Pablo Villacé 1 , Cristina Araguas 1 , Olivé Gema 1 , Silvia Vidal 1 , Luis Fernando Casas 2 , Berta Cisteró 1 , Maria Luisa Machado 1 . 1 Medicina Interna, Corporació Sanitaria Parc Tauli, Sabadell (barcelona); 2 Pneumologia, Corporació Sanitària Parc Tauli, Sabadell (barcelona) Introduction: There are some diagnostic and therapeutic measures to implement in the first 6h with the objective of decrease the mortality in 25%.
Objective: Analyze the clinics characteristics, the mortality rate and the diagnostic – therapeutics measures applied to a historical group (HG) of patients previous the implantation of “sepsis code” and a group of patients with sepsis after its implantation (GCS). Valuate the observation of the measures diagnostic-therapeutics recommended and the decrease of the mortality rate in the group post-implantation. Material and methods: A comparative before/after study between HG with the diagnosis of sepsis (January-march/2007) and GCS (January-march/2008) in which the sepsis code was activated. Intervention: Before the activation period, there were done several informative sessions for nurses, fellows and physicians about the activation of “sepsis code”. Activation criteria for sepsis code: 1. Infection suspicion, 2. Ta <36 or >38° o FC>90x’ or FR>20x’ or conscious level alteration, 3. Systolic arterial pressure <90mmHg or Medial arterial pressure <70mmHg. Exclusion criteria: patients who according to the physician were candidates to limitation of therapeutic measures. Clinical variables, comorbidity, the degree of achievement of the diagnostic – therapeutic measures and the intrahospitalary mortality rate were collected. Statistics. Chi square for the comparation of rates and t Student for the comparation of the averages rates using SPSS 15. Results: There were analyzed 51 patient with the diagnosis of sepsis (29 from GH and 22 from GCS). Average age was 73,68±13,27 years, 49% were men. Both groups were comparable in age, sex and comorbidity. The determination of lactic acid was 55,2% in the GH group vs 86,4% in the GCS, p= 0,017; hemoculture prelieve into the first three hours was 69% GH vs 95,5% GCS, p= 0,018, the administration of antibiotics previously the prelieve of hemoculture 62% GH vs 95,5% GCS, p=0.005, the medium volumen administration in the first hour was 825 ml Gh vs 1261 ml, p=0,009). The 77% of the patients was admitted for hospitalization (73% GH vs 82% GCS, p non significative) and the 23% was admitted in an intensive care area (27% GH vs 18,2% GCS, p ns). The 28 day mortality was 34,5% GH vs 9% GCS, p=0,034. Conclusions: The implantation of “sepsis code” in the emergency service, invol ve a significative improvement of the assistential quality of the patients, a better execution of the recommendations, a decrease of the admissions in the intensive care area, and a significative reduction of the mortality rate with a reduction of more than 25% in both groups.
P0769 PRIMARY LEFT PSOAS ABSCESS: AN UNUSUAL CASE REPORT
Ana Rafaela Alves, Luis Costa, Ana Ferreira, Madeira Ventura, Vaz Riscado. Hospital Curry Cabral Background: Primary psoas abscesses are a rare clinical entity with vague and non specific symptoms, most commonly seen in patients predisposed to infections. Early diagnosis and appropriate management are therefore challenging aspects for physicians. In Europe only 18.7% of psoas abscesses are primary and only 40% occur on the left side. Case report: We present a male 17 year old patient, who presented with fever, intense lower back pain that irradiated to the lower left limb and left iliac fossa with an inability to walk 4 days before admission. The pain did not improve with NSAIDs. He had no relevant personal history or predisposing factors and no other complaints preceding the clinical situation described. Lab tests revealed leucocytosis with neutrofilia, thrombocytosis, elevated PCR ad ESR. Vertebral CT showed an abscess of the left psoas muscle 38×23mm. Antibiotics were instituted, initially empirically with ciprofloxacin which was substituted with i.v. gentamicin and vancomycin after antibiogram for methicillin sensitive Staphylococcus aureus isolated in 3 blood cultures and abscess drainage was performed. During the etiologic investigation we found no other possible primary diseases that could cause psoas abscess such as digestive tract disease, tuberculosis, brucellosis, endocarditis, osteomyelitis or HIV. During hospital stay there was slow but progressive improvement. He underwent a control CT scan 4 weeks after admission which revealed a new smaller abscess, 15mm in diameter, located on the iliac muscle, on an inferior plane, as well as involvement of the contiguous left sacroiliac joint. MRI images showed inflammatory alterations of the sacroiliac joint. Due to marked clinical improvement with practically no functional compromise, we discharged the patient with oral fusidic acid antibiotherapy for 6 weeks and referred to our outpatient clinic. Follow-up shows complete clinical and radiologic remission. Conclusions: Psoas abscess is regarded as a rare entity in literature although it is probably increasing since the last decades. The causes also have been constantly changing and in recent years a primary psoas abscess due to haematogenous spread from an occult source is more common, especially in immunocompromised and older patients. S. aureus is found in 88% of primary psoas abscess and experimental data has shown that only after a muscle is
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
Results: Discharge at 32° day of Penicillin, resolution of amenorrhea, normal laboratory, abdomino-pelvic ultrasound with significant improvement. She was medicated with amoxicillin 1 g 8/8h po 6 months. Final diagnosis: Actinomycosis, co-infection by Bacteroides fragilis, Enterobacter faecium, Candida albicans and multifactorial anemia. Conclusions: The diagnosis of actinomycosis is very rare nowadays and it’s easily misdiagnosed as a cancer advanced disease. It has a good prognosis with proper diagnosis and medication. This extensive abdomino-pelvic form of actinomycosis occurred in a immunocompetent woman without intrauterine contraceptive device. Keywords: Actinomycosis
P0767 CASE REVIEW OF EMPIEMA NECESSITATIS
Silvia Vidal, Cristina Araguás, Xavi Pla, Pablo Villacé, Ester Oviedo, Gema Martinez. Medicina Interna, Corporació Sanitaria Parc Tauli. Sabadell (barcelona) Objectives: We reviewed all the cases of “Empiema Necessitatis” diagnosed in our hospital since 1996. We determine the features of comorbidity, treatment and patient’s evolution. We describe all the clinical, analytic, radiological, microbiological findings. Material and methods: Selection of 8 patients with a radiological diagnosis of Empiema Necessitatis. Retrospective review of all the medical histories. Collection of data in data base and descriptive analysis with statistic package SPSS v12. Results: (N=8).DEMOGRAPHICS: average age 72,8(39-84), sex (men 6 (75%)).COMORBIDITY: Smoking 25%(2), enol habit 25%(2), parental drug abusers (PDA) 1(12,5%), COPD 3(37,5%), history of TBC 5(62,5%). Previous pleural pathology 8(100%) of which 1 is for thoracotomy, 5 for pachypleuritis, 1 for deformities postTBC and 1 for asbestosys. Immunosuppressant 1 (12,5%) for HIV 1 (12,5%), none had neoplasm. Thoracic previous surgery 1 (12.5%), asbestos exposure 2 (25%). CLINIC: 4 patients had pain (50%), 4 fever (50%), 3 cough (not dry) (37,5%), 4 toxic syndrome (50%), 4 difficulty in breathing (50%), 5 were presenting thoracic mass (62,5%) and 1 respiratory insufficiency (12.5%). LABORATORY: Hb13,01g/dl (±1,5), Leukocytes 19690 10x6/L (±4399), neutrophils 7730 10x6/L (±4355), LDH 364U/L (±138), VSG 57,7mm1a h (±20,18), PCR 3,16mg/dL (±2,8), Cr 0,95mg/dl (±0,39), Albumen 34,6g/L (±4,6), Bilirrubin 0,6mg/dL (±0,3). ADA of the pleural liquid of 2 patients 69,3(±21). RADIOLOGY: In the simple radiology they presented: condensation 1 patient (12,5%), pleural effusion 3 (37,5%) and pleural widening 5(62.5%). In the evaluation by TC was observed: 100% (8) of the patients pleural effusion, 100% pleural affection and 62.5% (5) abscess of thoracic wall. MICROBIOLOGY: 2 exudate cultures +:1 Pseudomona (12,5%) and 1 Candida albicans (12,5%), 3 (32,5%) Lowenstein cultures were positive (none of them show a positive Ziehl Neelsen stain) and 2 patients did not have microbiological diagnosis. TREATMENT: 2 patients received antibiotic (25%), 3 Tuberculostatics (32,5%) and 1 antifungal treatment (12,5%). 2 needed a pleural drainage (25%) and 3 Surgery (32,5%). EVOLUTION: Resolution in 5 patients (62,5%), relapsed into 2 (25%) and 1 patient died for not related reason. Discussion: Some findings to stand out in our series:-description of one of the first cases of empiema necessitatis for candida albicans published-the fall rendibility diagnostic of the tint for bacilli resistant acid-alcohol in patients with positive Lowenstein culture,-the hight prevalence of precedent of pleural previous pathology (in 100% of the patients). Conclusions: Empiema necessitatis is a rare complication of a pleural Para pneumonic effusion not treated. The mycobacterium tuberculosis is the most frequent aetiology. The most relevant clinical feature is the presence of a thoracic mass. The utility of the TC and the PAAF in the diagnosis of this entity is widely demonstrated. We present an atypical case of fungi aetiology.
P0768 COMPARATIVE STUDY OF TWO GROUPS OF PATIENTS WITH SEVERE SEPSIS, BEFORE AND AFTER IMPLANTATION OF
Pablo Villacé 1 , Cristina Araguas 1 , Olivé Gema 1 , Silvia Vidal 1 , Luis Fernando Casas 2 , Berta Cisteró 1 , Maria Luisa Machado 1 . 1 Medicina Interna, Corporació Sanitaria Parc Tauli, Sabadell (barcelona); 2 Pneumologia, Corporació Sanitària Parc Tauli, Sabadell (barcelona) Introduction: There are some diagnostic and therapeutic measures to implement in the first 6h with the objective of decrease the mortality in 25%.
Objective: Analyze the clinics characteristics, the mortality rate and the diagnostic – therapeutics measures applied to a historical group (HG) of patients previous the implantation of “sepsis code” and a group of patients with sepsis after its implantation (GCS). Valuate the observation of the measures diagnostic-therapeutics recommended and the decrease of the mortality rate in the group post-implantation. Material and methods: A comparative before/after study between HG with the diagnosis of sepsis (January-march/2007) and GCS (January-march/2008) in which the sepsis code was activated. Intervention: Before the activation period, there were done several informative sessions for nurses, fellows and physicians about the activation of “sepsis code”. Activation criteria for sepsis code: 1. Infection suspicion, 2. Ta <36 or >38° o FC>90x’ or FR>20x’ or conscious level alteration, 3. Systolic arterial pressure <90mmHg or Medial arterial pressure <70mmHg. Exclusion criteria: patients who according to the physician were candidates to limitation of therapeutic measures. Clinical variables, comorbidity, the degree of achievement of the diagnostic – therapeutic measures and the intrahospitalary mortality rate were collected. Statistics. Chi square for the comparation of rates and t Student for the comparation of the averages rates using SPSS 15. Results: There were analyzed 51 patient with the diagnosis of sepsis (29 from GH and 22 from GCS). Average age was 73,68±13,27 years, 49% were men. Both groups were comparable in age, sex and comorbidity. The determination of lactic acid was 55,2% in the GH group vs 86,4% in the GCS, p= 0,017; hemoculture prelieve into the first three hours was 69% GH vs 95,5% GCS, p= 0,018, the administration of antibiotics previously the prelieve of hemoculture 62% GH vs 95,5% GCS, p=0.005, the medium volumen administration in the first hour was 825 ml Gh vs 1261 ml, p=0,009). The 77% of the patients was admitted for hospitalization (73% GH vs 82% GCS, p non significative) and the 23% was admitted in an intensive care area (27% GH vs 18,2% GCS, p ns). The 28 day mortality was 34,5% GH vs 9% GCS, p=0,034. Conclusions: The implantation of “sepsis code” in the emergency service, invol ve a significative improvement of the assistential quality of the patients, a better execution of the recommendations, a decrease of the admissions in the intensive care area, and a significative reduction of the mortality rate with a reduction of more than 25% in both groups.
P0769 PRIMARY LEFT PSOAS ABSCESS: AN UNUSUAL CASE REPORT
Ana Rafaela Alves, Luis Costa, Ana Ferreira, Madeira Ventura, Vaz Riscado. Hospital Curry Cabral Background: Primary psoas abscesses are a rare clinical entity with vague and non specific symptoms, most commonly seen in patients predisposed to infections. Early diagnosis and appropriate management are therefore challenging aspects for physicians. In Europe only 18.7% of psoas abscesses are primary and only 40% occur on the left side. Case report: We present a male 17 year old patient, who presented with fever, intense lower back pain that irradiated to the lower left limb and left iliac fossa with an inability to walk 4 days before admission. The pain did not improve with NSAIDs. He had no relevant personal history or predisposing factors and no other complaints preceding the clinical situation described. Lab tests revealed leucocytosis with neutrofilia, thrombocytosis, elevated PCR ad ESR. Vertebral CT showed an abscess of the left psoas muscle 38×23mm. Antibiotics were instituted, initially empirically with ciprofloxacin which was substituted with i.v. gentamicin and vancomycin after antibiogram for methicillin sensitive Staphylococcus aureus isolated in 3 blood cultures and abscess drainage was performed. During the etiologic investigation we found no other possible primary diseases that could cause psoas abscess such as digestive tract disease, tuberculosis, brucellosis, endocarditis, osteomyelitis or HIV. During hospital stay there was slow but progressive improvement. He underwent a control CT scan 4 weeks after admission which revealed a new smaller abscess, 15mm in diameter, located on the iliac muscle, on an inferior plane, as well as involvement of the contiguous left sacroiliac joint. MRI images showed inflammatory alterations of the sacroiliac joint. Due to marked clinical improvement with practically no functional compromise, we discharged the patient with oral fusidic acid antibiotherapy for 6 weeks and referred to our outpatient clinic. Follow-up shows complete clinical and radiologic remission. Conclusions: Psoas abscess is regarded as a rare entity in literature although it is probably increasing since the last decades. The causes also have been constantly changing and in recent years a primary psoas abscess due to haematogenous spread from an occult source is more common, especially in immunocompromised and older patients. S. aureus is found in 88% of primary psoas abscess and experimental data has shown that only after a muscle is