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P0774 MULTIFOCAL OSTEONECROSIS IN A HIV-INFECTED PATIENT
S252
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
to the increase in use of immunsuppressive drugs. They must be kept in mind as pathogens especially in immunocompromised patients.
P0772 TOXIC SHOCK SYNDROME
Cristiana Isabel Sevivas Sousa, Vasco Dias, Carla Teixeira, Fernanda Almeida, Fátima Farinha. Centro Hospitalar Do Porto - Hospital Santo António, Epe Toxic shock syndrome was initially described in the late 70s. It is a rare, potentially fatal, multisystem illness associated specially with S. aureus infection and production of superantigen toxins. Somehow, early cases were thought to be related to tampon use. Several reports have showed that toxic shock syndrome can be associated with many other etiologies: in the postoperative setting, in association with influenza, sinusitis, tracheitis, postpartum state, intravenous drug use, HIV infection, burn wounds ... Nowadays cases of toxic shock syndrome are less common. The authors present a specific case of a 24-year-old, healthy white female that was evaluated in the emergency room for fever, nauseas, vomits, diarrhoea, headaches, muscle aches, dry cough, rhinorhea and postural dizziness. Three weeks before, the patient has been seen by her physician for a urinary tract infection and she was medicated with co-trimoxazol; the symptoms had started during the 2nd day of her menstrual period. She was using a tampon. On her arrival to emergency room, her temperature was 39,5°C, the heart rate was 115 cpm and the blood pressure was 80/50 mmHg. She had signs of etmoidal and maxillary rhinossinusitis and pharyngitis. Her blood pressure started plummeting very quickly, without response to volume reposition and she went into shock a few hours after the arrival to the hospital. She developed other organs dysfunction (metabolic, haematological, respiratory and renal). She was transferred to the central care unit and started aggressive treatment. Two days after being admitted at the hospital, she presented a macular erythroderma, localized to the back, low extremities, palms and soles. A week later we observed desquamation of palms and soles, without scarring. It was isolated a staphylococcus aureus in the urine. Her evolution was positive and she was sent back home 4 weeks later. Our case has all diagnostic criteria for toxic shock syndrome caused by staphylococcus aureus. Other reasonable pathogens/diseases were excluded and no other cause for the shock was found. Nowadays cases of toxic shock syndrome are less common and several are missed by primary care providers mainly because of not thinking about the disorder. Our case is an interesting case of Toxic shock syndrome, with a dramatic course, probably related to tampon use.
P0773 SALMONELLA ENTERITIDIS SEVERE SEPSIS IN AN IMMUNOCOMPETENT YOUNG WOMAN
Joana Ramalho, Diana Valadares, Ana Campar, João Correia. Centro Hospitalar Do Porto Background: Infections due to Salmonella species represent a major public health problem in many countries. Nontyphoidal Salmonella is the most common pathogen implicated. Usually is a self-limiting disease that causes mild gastroenteritis, however, more serious extraintestinal findings, such as bacteraemia and focal infections localized to any organ, may appear. Aims: Demonstrate an unusually presentation of Salmonella infection. Case description: Previously healthy woman, 24 years, with onset of diarrhea (many dejections, without blood or mucous), vomits, abdominal pain and intense generalized weakness, with 6 hours of evolution. Consumption of well water and tomatoes pulp open a few days ago. At hospital admission, she was dehydrated, with shivering, tachycardia, hypotension and without peritoneal irritation at abdominal palpation. Worsening of the clinical picture during emergency room stay, with development of pancitopenia, oligoanuria, hypotension with need of amine support and acute abdomen with peritoneal irritation. Presenting with leucocitosis and elevation of c-reactive protein. Tomography demonstrate ascytis, colon and ileon oedema, with marked distension. Isolation of Salmonella non typhi, from D group, in blood and stool cultures. Salmonellosis with septic shock and multiorgan dysfunction. She starts antibiotics and gradually return to previous clinical state. Without immunodeficiencies detected. Conclusion: This case illustrates a severe septic shock in a immunocompetent young woman without comorbilities, from a pathogen that usually causes self-limiting episodes of diarrhea.
P0774 MULTIFOCAL OSTEONECROSIS IN A HIV-INFECTED PATIENT
Andreia Gonçalves, Isabel Pulido, Isabel Baptista. Centro Hospitalar De Lisboa Central, E.p.e. - Hospital De S. José Introduction: Osteonecrosis, also known as aseptic/avascular necrosis, results from compromise of the bone vasculature, leading to death of bone and marrow cells, with articular instability and progressively incapacitating pain. Although its etiology is still incompletely understood, it probably results from the sinergistic effect of a variety of mechanical, metabolic and endothelial factors. HIV infection seems to be an independent risk factor for developing osteonecrosis, particularly at the femoral head. Case report: We present the case of a 50-year-old male, with history of hypertension, previously followed in an Internal Medicine consultation for suspected systemic lupus erythematosus, which was not confirmed but led to a course of systemic glucocorticoid therapy. During investigation, sexually-transmitted HIV1 infection was diagnosed, without coinfections, and follow-up in an Immunodeficiency consultation was started. At that time, there were no criteria for initiation of antiretroviral therapy (CD4=402/mm3 , viral load=53000 copies/mL). Glucocorticoid medication had been stopped two years before. Some months thereafter, mechanical-type joint pain ensued, affecting predominantly the knees and right ankle, refractory to non-steroidal anti-inflammatory therapy. Imagiologic evaluation was highly suggestive of osteonecrosis, with areas of metaphisary intra-medullar and subcortical sclerosis in the left femur and both tibia, and in the postero-superior contour of the right femoral head. Symptoms became progressively worse and high activity antiretroviral therapy (HAART) was started, with marked improvement and only occasional need for analgesia. Discussion: Even though clinical improvement after the institution of HAART suggested a cause-effect relationship between HIV infection and bone disease, previous high-dose corticotherapy should be taken into account, since it leads to the changes in lipid metabolism and eventual venous stasis due to endothelial disfunction, with resultant increased intra-osseous pressure, being one of the factors probably involved in the pathogenesis of osteonecrosis. Conclusion: HIV-associated osteonecrosis should be considered in infected patients with persistent joint pain, and it can arise in any stage of the retroviral disease. Keywords: osteonecrosis, HIV infection, high activity antiretroviral therapy.
P0775 URINARY TRACT INFECTIONS IN AN INTERNAL MEDICINE WARD: A RETROSPECTIVE STUDY
Alexandra Freitas, Ricardo Rangel, Sofia Torres, Ana Grilo, Carla Noronha, Miguel Sousa, António Panarra, Manuel Vaz Riscado. Hospital Curry Cabral Introduction: Urinary Tract Infections (UTI) are a common cause not only of admission to an Internal Medicine ward, but also of significant co-morbidity. Objectives: characterization of UTI admissions in an Internal Medicine ward, during one year, in its epidemiologic, clinical, microbiological and therapeutic aspects, as well as patient outcome. Design and methods: systematic review of clinical files of patients admitted and/or discharged with the diagnosis of UTI, in any clinical presentation, during the year of 2007. Results: A total of 1640 patients were admitted to our ward during 2007. Of these, 11,52% (40 males, 139 females) had a diagnosis of UTI. Average age was 75.7. UTI was an admission diagnosis in 68,25% of these patients, and was the main diagnosis at discharge in 25,93% of them. Urine culture was performed in over 90% of patients, and yielded positive results in 40,35%. No differences in yield were found if culture was performed on admission or in the following 72 hours. The most common isolates were: Escherichia coli, Enterococcus faecalis and Klebsiella pneumoniae. As for antibiotics sensitivity, 6%, 0% and 50%, respectively, were resistant to amoxicillin and 42%, 55.5% and 50%, respectively, were resistant to fluoroquinolones, still widely used as empirical therapy. Mortality directly attributable to septic complications of UTI was 24%. Conclusions: UTI are an important co-morbidity and mortality factor in an Internal Medicine ward. Urine culture yield was moderate, and unrelated, apparently, with the precocity of sample collection. Microbiological aspects are of paramount importance in this regard, allowing optimization of empirical antibiotherapy to each place’s reality.
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
to the increase in use of immunsuppressive drugs. They must be kept in mind as pathogens especially in immunocompromised patients.
P0772 TOXIC SHOCK SYNDROME
Cristiana Isabel Sevivas Sousa, Vasco Dias, Carla Teixeira, Fernanda Almeida, Fátima Farinha. Centro Hospitalar Do Porto - Hospital Santo António, Epe Toxic shock syndrome was initially described in the late 70s. It is a rare, potentially fatal, multisystem illness associated specially with S. aureus infection and production of superantigen toxins. Somehow, early cases were thought to be related to tampon use. Several reports have showed that toxic shock syndrome can be associated with many other etiologies: in the postoperative setting, in association with influenza, sinusitis, tracheitis, postpartum state, intravenous drug use, HIV infection, burn wounds ... Nowadays cases of toxic shock syndrome are less common. The authors present a specific case of a 24-year-old, healthy white female that was evaluated in the emergency room for fever, nauseas, vomits, diarrhoea, headaches, muscle aches, dry cough, rhinorhea and postural dizziness. Three weeks before, the patient has been seen by her physician for a urinary tract infection and she was medicated with co-trimoxazol; the symptoms had started during the 2nd day of her menstrual period. She was using a tampon. On her arrival to emergency room, her temperature was 39,5°C, the heart rate was 115 cpm and the blood pressure was 80/50 mmHg. She had signs of etmoidal and maxillary rhinossinusitis and pharyngitis. Her blood pressure started plummeting very quickly, without response to volume reposition and she went into shock a few hours after the arrival to the hospital. She developed other organs dysfunction (metabolic, haematological, respiratory and renal). She was transferred to the central care unit and started aggressive treatment. Two days after being admitted at the hospital, she presented a macular erythroderma, localized to the back, low extremities, palms and soles. A week later we observed desquamation of palms and soles, without scarring. It was isolated a staphylococcus aureus in the urine. Her evolution was positive and she was sent back home 4 weeks later. Our case has all diagnostic criteria for toxic shock syndrome caused by staphylococcus aureus. Other reasonable pathogens/diseases were excluded and no other cause for the shock was found. Nowadays cases of toxic shock syndrome are less common and several are missed by primary care providers mainly because of not thinking about the disorder. Our case is an interesting case of Toxic shock syndrome, with a dramatic course, probably related to tampon use.
P0773 SALMONELLA ENTERITIDIS SEVERE SEPSIS IN AN IMMUNOCOMPETENT YOUNG WOMAN
Joana Ramalho, Diana Valadares, Ana Campar, João Correia. Centro Hospitalar Do Porto Background: Infections due to Salmonella species represent a major public health problem in many countries. Nontyphoidal Salmonella is the most common pathogen implicated. Usually is a self-limiting disease that causes mild gastroenteritis, however, more serious extraintestinal findings, such as bacteraemia and focal infections localized to any organ, may appear. Aims: Demonstrate an unusually presentation of Salmonella infection. Case description: Previously healthy woman, 24 years, with onset of diarrhea (many dejections, without blood or mucous), vomits, abdominal pain and intense generalized weakness, with 6 hours of evolution. Consumption of well water and tomatoes pulp open a few days ago. At hospital admission, she was dehydrated, with shivering, tachycardia, hypotension and without peritoneal irritation at abdominal palpation. Worsening of the clinical picture during emergency room stay, with development of pancitopenia, oligoanuria, hypotension with need of amine support and acute abdomen with peritoneal irritation. Presenting with leucocitosis and elevation of c-reactive protein. Tomography demonstrate ascytis, colon and ileon oedema, with marked distension. Isolation of Salmonella non typhi, from D group, in blood and stool cultures. Salmonellosis with septic shock and multiorgan dysfunction. She starts antibiotics and gradually return to previous clinical state. Without immunodeficiencies detected. Conclusion: This case illustrates a severe septic shock in a immunocompetent young woman without comorbilities, from a pathogen that usually causes self-limiting episodes of diarrhea.
P0774 MULTIFOCAL OSTEONECROSIS IN A HIV-INFECTED PATIENT
Andreia Gonçalves, Isabel Pulido, Isabel Baptista. Centro Hospitalar De Lisboa Central, E.p.e. - Hospital De S. José Introduction: Osteonecrosis, also known as aseptic/avascular necrosis, results from compromise of the bone vasculature, leading to death of bone and marrow cells, with articular instability and progressively incapacitating pain. Although its etiology is still incompletely understood, it probably results from the sinergistic effect of a variety of mechanical, metabolic and endothelial factors. HIV infection seems to be an independent risk factor for developing osteonecrosis, particularly at the femoral head. Case report: We present the case of a 50-year-old male, with history of hypertension, previously followed in an Internal Medicine consultation for suspected systemic lupus erythematosus, which was not confirmed but led to a course of systemic glucocorticoid therapy. During investigation, sexually-transmitted HIV1 infection was diagnosed, without coinfections, and follow-up in an Immunodeficiency consultation was started. At that time, there were no criteria for initiation of antiretroviral therapy (CD4=402/mm3 , viral load=53000 copies/mL). Glucocorticoid medication had been stopped two years before. Some months thereafter, mechanical-type joint pain ensued, affecting predominantly the knees and right ankle, refractory to non-steroidal anti-inflammatory therapy. Imagiologic evaluation was highly suggestive of osteonecrosis, with areas of metaphisary intra-medullar and subcortical sclerosis in the left femur and both tibia, and in the postero-superior contour of the right femoral head. Symptoms became progressively worse and high activity antiretroviral therapy (HAART) was started, with marked improvement and only occasional need for analgesia. Discussion: Even though clinical improvement after the institution of HAART suggested a cause-effect relationship between HIV infection and bone disease, previous high-dose corticotherapy should be taken into account, since it leads to the changes in lipid metabolism and eventual venous stasis due to endothelial disfunction, with resultant increased intra-osseous pressure, being one of the factors probably involved in the pathogenesis of osteonecrosis. Conclusion: HIV-associated osteonecrosis should be considered in infected patients with persistent joint pain, and it can arise in any stage of the retroviral disease. Keywords: osteonecrosis, HIV infection, high activity antiretroviral therapy.
P0775 URINARY TRACT INFECTIONS IN AN INTERNAL MEDICINE WARD: A RETROSPECTIVE STUDY
Alexandra Freitas, Ricardo Rangel, Sofia Torres, Ana Grilo, Carla Noronha, Miguel Sousa, António Panarra, Manuel Vaz Riscado. Hospital Curry Cabral Introduction: Urinary Tract Infections (UTI) are a common cause not only of admission to an Internal Medicine ward, but also of significant co-morbidity. Objectives: characterization of UTI admissions in an Internal Medicine ward, during one year, in its epidemiologic, clinical, microbiological and therapeutic aspects, as well as patient outcome. Design and methods: systematic review of clinical files of patients admitted and/or discharged with the diagnosis of UTI, in any clinical presentation, during the year of 2007. Results: A total of 1640 patients were admitted to our ward during 2007. Of these, 11,52% (40 males, 139 females) had a diagnosis of UTI. Average age was 75.7. UTI was an admission diagnosis in 68,25% of these patients, and was the main diagnosis at discharge in 25,93% of them. Urine culture was performed in over 90% of patients, and yielded positive results in 40,35%. No differences in yield were found if culture was performed on admission or in the following 72 hours. The most common isolates were: Escherichia coli, Enterococcus faecalis and Klebsiella pneumoniae. As for antibiotics sensitivity, 6%, 0% and 50%, respectively, were resistant to amoxicillin and 42%, 55.5% and 50%, respectively, were resistant to fluoroquinolones, still widely used as empirical therapy. Mortality directly attributable to septic complications of UTI was 24%. Conclusions: UTI are an important co-morbidity and mortality factor in an Internal Medicine ward. Urine culture yield was moderate, and unrelated, apparently, with the precocity of sample collection. Microbiological aspects are of paramount importance in this regard, allowing optimization of empirical antibiotherapy to each place’s reality.