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The secret behind the stroke: A case report
Abstracts
ID: 727 Disseminated Mycobacterium bovis infection: Late complication of intravesical instillation of Bacillus Calmette-Guérin L. Lêdo, P. Gaspar da Costa, D. Correia, S. Braz, J. Meneses Santos, R.M.M. Victorino Department of Medicine 2, Hospital de Santa Maria, CHLN/Faculty of Medicine Of Lisbon, Lisbon, Portugal
Immunotherapy with BCG, a live attenuated strain of Mycobacterium bovis, is a well known and effective therapy in the treatment of superficial bladder cancer. Although considered a relatively safe treatment, local and systemic complications may occur. Late disseminated infection manifested 1 year or more after the first BCG intravesical instillation is rare, occurring in 1% of the patients. There are less than 50 cases of late-presentation infection described in the literature. The authors present the case of an 80 year-old male patient with a known diagnosis of bladder carcinoma. Two years earlier he underwent transurethral resection of the bladder tumor followed by intravesical BCG instillation therapy. His past medical history was remarkable for several comorbidities namely chronic kidney disease on hemodialysis treatment. The patient presented with asthenia, occasional low grade fever and night sweats for the last 12 months. These complaints were attributable to urinary tract infections and the patient was started on quinolones for several times for the last months. An isolated generalized seizure was reported during a previous hospital course 1 month earlier. His bladder cancer remained in remission. On physical examination the patient was cachectic and had no adenopathies or meningeal signs. Laboratory investigation showed pancytopenia. Computed tomography scan of the abdomen revealed hepatomegaly, splenomegaly and several abdominal aorta aneurysms. The bone marrow biopsy showed noncaseating granulomas. A lumbar puncture was made and the cerebrospinal fluid analysis revealed pleocytosis with a lymphocyte predominance, diminished glucose levels and elevated protein levels and adenosine deaminase. M. bovis was isolated in the bone marrow and bronchoalveolar lavage cultures by polymerase chain reaction assay was performed confirming the diagnosis of M. bovis disseminated infection. The patient died 2 weeks after antituberculous therapy was started. This case illustrates a rare late complication of intravesical BCG instillation. We highlight the multisystemic infection involvement (meninges, lung, bone marrow and abdominal aorta walls) and the isolation of M. bovis in two distinct locations (lung and bone marrow). We assumed that the insidious clinical presentation could be due to the anti-bacilar activity of quinolones prescribed for several times prior to hospital admission. doi:10.1016/j.ejim.2013.08.560
ID: 731 Klebsiella pneumoniae invasive infection in an immunocompetent patient C.E. Santoa, G. Correiab, T. Marquesb, A.J. Acabadoa, J.B. Nogueiraa a Department of Internal Medicine 1, Hospital de Santa Maria/Centro Hospitalar de Lisboa Norte, Faculdade de Medicina de Lisboa, Lisbon, Portugal b Department of Infectious Diseases, Hospital de Santa Maria/Centro Hospitalar de Lisboa Norte, Lisbon, Portugal
Objective: Infections with Klebsiella pneumoniae are usually hospital-acquired and occur primarily in patients with impaired host defenses. Our aim is to demonstrate that invasive K. pneumoniae
e219
infections can also occur in immunocompetent patients. Methods: We report the case of a young healthy adult who developed an invasive K. pneumoniae infection, with involvement of the central nervous system (CNS). The report is given in light of the relevant literature, which is briefly reviewed. Results: A 33-year-old healthy man had been diagnosed with perforated appendicitis complicated by peritonitis and K. pneumoniae bacteremia. He underwent abdominal surgery and antibiotic treatment. A few weeks later, he presented with fever, nuchal rigidity, a change in mental status and cerebrospinal fluid (CSF) pleocytosis; the CSF bacteriologic exam revealed K. pneumoniae. The bacterial meningitis was treated with the antibiotic determined by the results of susceptibility testing, with ensuing clinical and analytical recovery. Meanwhile, he presented with thoracic tenderness, and imaging studies were compatible with spondylodiscitis. Endocarditis and hepatic abscess were excluded. The antibiotic treatment was prolonged for four months with clinical success. The immunological study showed no immunodeficiency. Discussion and Conclusions: K. pneumoniae is primarily a nosocomial pathogen that has been associated with urinary tract infection, pulmonary infection, bacteremia, and other infections in susceptible individuals. Our patient did not have any of the risk factors described for this agent, yet he developed a disseminated/metastatic infection. Certain virulent strains are prone to cause a destructive abscess syndrome with possible metastatic infection in an immunocompetent host. This case adds to existing reports on this syndrome, and reinforces the importance of keeping in mind the hypothesis of K. pneumoniae as a causative agent even in the setting of an invasive/ metastatic infection, with CNS involvement, in an immunocompetent patient.
doi:10.1016/j.ejim.2013.08.561
ID: 742 The secret behind the stroke: A case report S. Rodrigues, M. Manso, S. Rodeia, R. Domingos, F. Silva, A.M. Silva Serviço de Medicina II, Hospital Egas Moniz, CHLO, Lisboa, Portugal
Malignant otitis externa (MOE) is a life-threatening infection of the skull base, occurring mostly in diabetic patients. Its presentation is not always typical, varying from local symptoms to severe neurologic complications. Prognosis is highly variable, depending on early recognition and aggressive therapy. The authors describe a case of a 81-year-old female with poorly controlled type 2 diabetes admitted with left hemiparesis and left homonym hemianopsia. Concurrently, she complained of severe occipital headache, with irradiation to the cervical right region, in the previous month. On admission, a brain computed tomography (CT) revealed no secure ischemic lesion (although bilateral lacunar infarctions were present) and a mass in the right pharyngeal mucosal space, with tissue inflammation and necrosis. A previous history of chronic otitis media and a mild elevation of inflammatory markers were then valued and the requested magnetic resonance lead to the diagnosis of MOE, complicated by extensive skull base osteomyelitis with cranial nerve foramina involvement and internal carotid vasculitis, with significant stenosis of the arterial lumen. This inflammatory condition was presumed to be the cause of the stroke she presented with. In all collected samples, Pseudomonas aeruginosa was isolated and double targeted antibiotic treatment was started, in association with hyperbaric oxygen therapy. Six week CT control showed signs of amelioration of soft tissue infection and bony remineralisation. Unfortunately, the patient died shortly after of unknown cause.
e220
Abstracts
Although neurological involvement is frequent in this condition, with known complications as meningitis, cerebral abscess, and septical dural sinus trombosis, the involvement of the carotid artery with consequent ischemic stroke has not been described. By presenting this case, where the complication revealed the condition, the authors pretend to underline how MOE can be a severe disease with complex management. doi:10.1016/j.ejim.2013.08.562
ID: 748 Ramsey Hunt syndrome — a case report A. Silva Department of Internal Medicine, Hospital São João, Porto, Portugal
Case report: An 82-year-old woman with a history of hypertension and diabetes mellitus was presented to the Emergency Room (ER) because of left facial weakness of sudden onset and pain on the mastoid region. She had a history of a recent viral upper airway infection. On examination, she had a peripheral left facial nerve paralysis, with no other abnormalities. She was diagnosed with a Bell's Palsy and discharged from the ER with a prescription of prednisolon and recommendation for eye care measures. After 4 days she was back to the ER, referring vertigo, nausea, vomiting and tinnitus. On examination, she had a vesicular rash on the left external ear; she had no hearing impairment. The diagnosis of a Ramsay-Hunt syndrome was made and she was discharged with an additional prescription of valaciclovir 800 mg po tid. Discussion: Bell's palsy is as an idiopathic acute peripheral facial nerve palsy, with an annual incidence of around 30 cases per 100,000 people. Prognosis is generally good, with most patients recovering completely. Herpes simplex virus (HSV) type 1 is probably the most common cause of acute onset peripheral facial palsy. Other infectious causes include varicella–zoster virus (VZV), cytomegalovirus, Epstein Barr virus, adenovirus, rubella virus, mumps, influenza B, and coxsackievirus. Treatment remains controversial: overall, data suggest that glucocorticoids decrease the incidence of permanent facial paralysis, but more studies are needed to determine whether antiviral therapy confers additional benefit. The Ramsay Hunt syndrome (herpes zoster oticus) consists on the reactivation of latent VZV from the geniculate ganglion, with involvement of the eighth cranial nerve (and possibly of the fifth, ninth and tenth). It typically includes facial paralysis, ear pain, vesicles in the auditory canal and auricle, and vertigo. Hearing, taste perception and lacrimation can be affected. The facial paralysis in Ramsey Hunt syndrome is generally associated to a poorer prognosis than that caused by HSV. It is usually managed with antivirals, although not much is known about this complication of VZV infection. doi:10.1016/j.ejim.2013.08.563
ID: 754 Listeria monocytogenes infections in a tertiary hospital G.M. Lledó, P. Laguna-Del Estal, R. Ríos, I. Pintos, J.F. Montoro, C. Gómez, A. Anula, J.A. Alonso Internal Medicine, Hospital Puerta de Hierro de Majadahonda, Madrid, Spain
Introduction: Listeria monocytogenes is still an important cause of infection, mainly in the central nervous system (CNS), and is the
third most common cause of community-acquired bacterial meningitis in adults. Objectives: To describe the characteristics of Listeria infections in adults to determine the main predisposing factors, clinical course and outcomes, depending on which empirical antibiotics and drugs were administered after the antiobiogram. Patients and methods: A retrospective analysis of a series of cases was conducted in a tertiary hospital in Madrid, including patients with Listeria infection between 1996 and 2011. Results: 26 cases of Listeria infection were reported, 14 of them were central nervous system infections (13 meningitis and one abscess), 3 abdominal infections, 1 ophthalmic infection and 8 bacteremias with no focus identified. All the central nervous system infections were community-acquired. Three of the remaining cases had nosocomial infections. The most important predisposing factors were: age N 50 years in 69% of the patients, immunosuppression in 54%, liver diseases in 23% (66.6% chronic liver disease, 16.6% autoimmune liver disease, 16.6% reactivation of HBV) and concomitant oncological process in 34.4% of the patients (15.4% hematologic cancer and 19% solid tumors). 89% of the patients had fever at the time of admission and 50% presented with low level of consciousness. In most cases antibiograms were available and we could check drug sensitivity such as ampicillin, gentamicin, TMP-SMX and other drugs less-used in usual clinical practice like linezolid or vancomycin. The mortality rate of this selection was 23%, half of which were contributed to listeria. Conclusion: Listeria is already an important cause of central nervous system infection, above all in cases of meningitis. It also played an important role in isolated bacteremia infections. Age and immunosuppression are the most important predisposing factors in patients. Nowadays, fever and altered level of consciousness are typical clinical presentations. There was a low mortality rate because patients, in general, received appropriate treatment. doi:10.1016/j.ejim.2013.08.564
ID: 756 Sudden lumbar pain and fever Filipa Pais da Silva, Catarina Patrício, Pedro Eduardo Silva, Rui Pereira, Vitor Brotas Internal Medicine department 3, Hospital Santo António dos Capuchos, Lisbon, Portugal Objective: The authors aim to take into consideration the importance of an enriching clinical discussion, facing every diagnostic possibility. Methods: The authors report a case suggestive of infectious endocarditis. Results: This thirty seven year old patient, with known history of I.V. drug addiction, was sent to an Internal Medicine specialist after a previous observation at the emergency room, due to five days of fever and abdominal pain. At presentation he had fever, left abdominal flank pain, renal Murphy sign, hepatomegaly and splenomegaly; the initial etiological study included routine blood tests and cultures (which revealed increased acute inflammatory parameters), thoracic X-ray (with multiple, nodular, heterogeneous focal lesions), as well as abdominal and renal ultrasounds (without relevant aspects, except hepatomegaly and splenomegaly). He was then admitted into the internal medicine ward, where he was started on antibiotics, admitting bacterial endocarditis related to his I.V. drug addiction. Methicillin-resistant staphylococcus aureus (MRSA) was isolated from blood cultures; a patent foramen ovale (PFO) was detected in the transesophageal echocardiography but no vegetations were identified; the thoracic computerized tomography (CT) scan defined multiple nodular cavitated lesions that suggested septic embolization. Due to sudden visual acuity loss, red eye and intense pain, he was evaluated by an
ID: 727 Disseminated Mycobacterium bovis infection: Late complication of intravesical instillation of Bacillus Calmette-Guérin L. Lêdo, P. Gaspar da Costa, D. Correia, S. Braz, J. Meneses Santos, R.M.M. Victorino Department of Medicine 2, Hospital de Santa Maria, CHLN/Faculty of Medicine Of Lisbon, Lisbon, Portugal
Immunotherapy with BCG, a live attenuated strain of Mycobacterium bovis, is a well known and effective therapy in the treatment of superficial bladder cancer. Although considered a relatively safe treatment, local and systemic complications may occur. Late disseminated infection manifested 1 year or more after the first BCG intravesical instillation is rare, occurring in 1% of the patients. There are less than 50 cases of late-presentation infection described in the literature. The authors present the case of an 80 year-old male patient with a known diagnosis of bladder carcinoma. Two years earlier he underwent transurethral resection of the bladder tumor followed by intravesical BCG instillation therapy. His past medical history was remarkable for several comorbidities namely chronic kidney disease on hemodialysis treatment. The patient presented with asthenia, occasional low grade fever and night sweats for the last 12 months. These complaints were attributable to urinary tract infections and the patient was started on quinolones for several times for the last months. An isolated generalized seizure was reported during a previous hospital course 1 month earlier. His bladder cancer remained in remission. On physical examination the patient was cachectic and had no adenopathies or meningeal signs. Laboratory investigation showed pancytopenia. Computed tomography scan of the abdomen revealed hepatomegaly, splenomegaly and several abdominal aorta aneurysms. The bone marrow biopsy showed noncaseating granulomas. A lumbar puncture was made and the cerebrospinal fluid analysis revealed pleocytosis with a lymphocyte predominance, diminished glucose levels and elevated protein levels and adenosine deaminase. M. bovis was isolated in the bone marrow and bronchoalveolar lavage cultures by polymerase chain reaction assay was performed confirming the diagnosis of M. bovis disseminated infection. The patient died 2 weeks after antituberculous therapy was started. This case illustrates a rare late complication of intravesical BCG instillation. We highlight the multisystemic infection involvement (meninges, lung, bone marrow and abdominal aorta walls) and the isolation of M. bovis in two distinct locations (lung and bone marrow). We assumed that the insidious clinical presentation could be due to the anti-bacilar activity of quinolones prescribed for several times prior to hospital admission. doi:10.1016/j.ejim.2013.08.560
ID: 731 Klebsiella pneumoniae invasive infection in an immunocompetent patient C.E. Santoa, G. Correiab, T. Marquesb, A.J. Acabadoa, J.B. Nogueiraa a Department of Internal Medicine 1, Hospital de Santa Maria/Centro Hospitalar de Lisboa Norte, Faculdade de Medicina de Lisboa, Lisbon, Portugal b Department of Infectious Diseases, Hospital de Santa Maria/Centro Hospitalar de Lisboa Norte, Lisbon, Portugal
Objective: Infections with Klebsiella pneumoniae are usually hospital-acquired and occur primarily in patients with impaired host defenses. Our aim is to demonstrate that invasive K. pneumoniae
e219
infections can also occur in immunocompetent patients. Methods: We report the case of a young healthy adult who developed an invasive K. pneumoniae infection, with involvement of the central nervous system (CNS). The report is given in light of the relevant literature, which is briefly reviewed. Results: A 33-year-old healthy man had been diagnosed with perforated appendicitis complicated by peritonitis and K. pneumoniae bacteremia. He underwent abdominal surgery and antibiotic treatment. A few weeks later, he presented with fever, nuchal rigidity, a change in mental status and cerebrospinal fluid (CSF) pleocytosis; the CSF bacteriologic exam revealed K. pneumoniae. The bacterial meningitis was treated with the antibiotic determined by the results of susceptibility testing, with ensuing clinical and analytical recovery. Meanwhile, he presented with thoracic tenderness, and imaging studies were compatible with spondylodiscitis. Endocarditis and hepatic abscess were excluded. The antibiotic treatment was prolonged for four months with clinical success. The immunological study showed no immunodeficiency. Discussion and Conclusions: K. pneumoniae is primarily a nosocomial pathogen that has been associated with urinary tract infection, pulmonary infection, bacteremia, and other infections in susceptible individuals. Our patient did not have any of the risk factors described for this agent, yet he developed a disseminated/metastatic infection. Certain virulent strains are prone to cause a destructive abscess syndrome with possible metastatic infection in an immunocompetent host. This case adds to existing reports on this syndrome, and reinforces the importance of keeping in mind the hypothesis of K. pneumoniae as a causative agent even in the setting of an invasive/ metastatic infection, with CNS involvement, in an immunocompetent patient.
doi:10.1016/j.ejim.2013.08.561
ID: 742 The secret behind the stroke: A case report S. Rodrigues, M. Manso, S. Rodeia, R. Domingos, F. Silva, A.M. Silva Serviço de Medicina II, Hospital Egas Moniz, CHLO, Lisboa, Portugal
Malignant otitis externa (MOE) is a life-threatening infection of the skull base, occurring mostly in diabetic patients. Its presentation is not always typical, varying from local symptoms to severe neurologic complications. Prognosis is highly variable, depending on early recognition and aggressive therapy. The authors describe a case of a 81-year-old female with poorly controlled type 2 diabetes admitted with left hemiparesis and left homonym hemianopsia. Concurrently, she complained of severe occipital headache, with irradiation to the cervical right region, in the previous month. On admission, a brain computed tomography (CT) revealed no secure ischemic lesion (although bilateral lacunar infarctions were present) and a mass in the right pharyngeal mucosal space, with tissue inflammation and necrosis. A previous history of chronic otitis media and a mild elevation of inflammatory markers were then valued and the requested magnetic resonance lead to the diagnosis of MOE, complicated by extensive skull base osteomyelitis with cranial nerve foramina involvement and internal carotid vasculitis, with significant stenosis of the arterial lumen. This inflammatory condition was presumed to be the cause of the stroke she presented with. In all collected samples, Pseudomonas aeruginosa was isolated and double targeted antibiotic treatment was started, in association with hyperbaric oxygen therapy. Six week CT control showed signs of amelioration of soft tissue infection and bony remineralisation. Unfortunately, the patient died shortly after of unknown cause.
e220
Abstracts
Although neurological involvement is frequent in this condition, with known complications as meningitis, cerebral abscess, and septical dural sinus trombosis, the involvement of the carotid artery with consequent ischemic stroke has not been described. By presenting this case, where the complication revealed the condition, the authors pretend to underline how MOE can be a severe disease with complex management. doi:10.1016/j.ejim.2013.08.562
ID: 748 Ramsey Hunt syndrome — a case report A. Silva Department of Internal Medicine, Hospital São João, Porto, Portugal
Case report: An 82-year-old woman with a history of hypertension and diabetes mellitus was presented to the Emergency Room (ER) because of left facial weakness of sudden onset and pain on the mastoid region. She had a history of a recent viral upper airway infection. On examination, she had a peripheral left facial nerve paralysis, with no other abnormalities. She was diagnosed with a Bell's Palsy and discharged from the ER with a prescription of prednisolon and recommendation for eye care measures. After 4 days she was back to the ER, referring vertigo, nausea, vomiting and tinnitus. On examination, she had a vesicular rash on the left external ear; she had no hearing impairment. The diagnosis of a Ramsay-Hunt syndrome was made and she was discharged with an additional prescription of valaciclovir 800 mg po tid. Discussion: Bell's palsy is as an idiopathic acute peripheral facial nerve palsy, with an annual incidence of around 30 cases per 100,000 people. Prognosis is generally good, with most patients recovering completely. Herpes simplex virus (HSV) type 1 is probably the most common cause of acute onset peripheral facial palsy. Other infectious causes include varicella–zoster virus (VZV), cytomegalovirus, Epstein Barr virus, adenovirus, rubella virus, mumps, influenza B, and coxsackievirus. Treatment remains controversial: overall, data suggest that glucocorticoids decrease the incidence of permanent facial paralysis, but more studies are needed to determine whether antiviral therapy confers additional benefit. The Ramsay Hunt syndrome (herpes zoster oticus) consists on the reactivation of latent VZV from the geniculate ganglion, with involvement of the eighth cranial nerve (and possibly of the fifth, ninth and tenth). It typically includes facial paralysis, ear pain, vesicles in the auditory canal and auricle, and vertigo. Hearing, taste perception and lacrimation can be affected. The facial paralysis in Ramsey Hunt syndrome is generally associated to a poorer prognosis than that caused by HSV. It is usually managed with antivirals, although not much is known about this complication of VZV infection. doi:10.1016/j.ejim.2013.08.563
ID: 754 Listeria monocytogenes infections in a tertiary hospital G.M. Lledó, P. Laguna-Del Estal, R. Ríos, I. Pintos, J.F. Montoro, C. Gómez, A. Anula, J.A. Alonso Internal Medicine, Hospital Puerta de Hierro de Majadahonda, Madrid, Spain
Introduction: Listeria monocytogenes is still an important cause of infection, mainly in the central nervous system (CNS), and is the
third most common cause of community-acquired bacterial meningitis in adults. Objectives: To describe the characteristics of Listeria infections in adults to determine the main predisposing factors, clinical course and outcomes, depending on which empirical antibiotics and drugs were administered after the antiobiogram. Patients and methods: A retrospective analysis of a series of cases was conducted in a tertiary hospital in Madrid, including patients with Listeria infection between 1996 and 2011. Results: 26 cases of Listeria infection were reported, 14 of them were central nervous system infections (13 meningitis and one abscess), 3 abdominal infections, 1 ophthalmic infection and 8 bacteremias with no focus identified. All the central nervous system infections were community-acquired. Three of the remaining cases had nosocomial infections. The most important predisposing factors were: age N 50 years in 69% of the patients, immunosuppression in 54%, liver diseases in 23% (66.6% chronic liver disease, 16.6% autoimmune liver disease, 16.6% reactivation of HBV) and concomitant oncological process in 34.4% of the patients (15.4% hematologic cancer and 19% solid tumors). 89% of the patients had fever at the time of admission and 50% presented with low level of consciousness. In most cases antibiograms were available and we could check drug sensitivity such as ampicillin, gentamicin, TMP-SMX and other drugs less-used in usual clinical practice like linezolid or vancomycin. The mortality rate of this selection was 23%, half of which were contributed to listeria. Conclusion: Listeria is already an important cause of central nervous system infection, above all in cases of meningitis. It also played an important role in isolated bacteremia infections. Age and immunosuppression are the most important predisposing factors in patients. Nowadays, fever and altered level of consciousness are typical clinical presentations. There was a low mortality rate because patients, in general, received appropriate treatment. doi:10.1016/j.ejim.2013.08.564
ID: 756 Sudden lumbar pain and fever Filipa Pais da Silva, Catarina Patrício, Pedro Eduardo Silva, Rui Pereira, Vitor Brotas Internal Medicine department 3, Hospital Santo António dos Capuchos, Lisbon, Portugal Objective: The authors aim to take into consideration the importance of an enriching clinical discussion, facing every diagnostic possibility. Methods: The authors report a case suggestive of infectious endocarditis. Results: This thirty seven year old patient, with known history of I.V. drug addiction, was sent to an Internal Medicine specialist after a previous observation at the emergency room, due to five days of fever and abdominal pain. At presentation he had fever, left abdominal flank pain, renal Murphy sign, hepatomegaly and splenomegaly; the initial etiological study included routine blood tests and cultures (which revealed increased acute inflammatory parameters), thoracic X-ray (with multiple, nodular, heterogeneous focal lesions), as well as abdominal and renal ultrasounds (without relevant aspects, except hepatomegaly and splenomegaly). He was then admitted into the internal medicine ward, where he was started on antibiotics, admitting bacterial endocarditis related to his I.V. drug addiction. Methicillin-resistant staphylococcus aureus (MRSA) was isolated from blood cultures; a patent foramen ovale (PFO) was detected in the transesophageal echocardiography but no vegetations were identified; the thoracic computerized tomography (CT) scan defined multiple nodular cavitated lesions that suggested septic embolization. Due to sudden visual acuity loss, red eye and intense pain, he was evaluated by an