Recurrent thrombosis as a clinical presentation of Whipple disease.

Whipple's disease (WD) is a rare infectious disease with a wide clinical spectrum. Associated thrombotic manifestations are not well described in WD, only related to 'stroke-like syndrome'. We present a case of a 39-year-old man with a 1-year history of self-limited episodes of fever, associated with generalised adenopathies and recurrent superficial and deep venous thrombosis events, which have resorted four times despite the anticoagulant treatment. Finally, the patient is diagnosed with WD. Following treatment the patient improved in his general condition, and no more episodes of fever neither thrombosis appeared during a follow-up of more than 3 years.

Long-term follow-up of jaw osteomyelitis associated with bisphosphonate use in a tertiary-care center.

OBJECTIVES: This study reviews our experience in bisphosphonate-associated jaw osteomyelitis (BJOM), focusing on the incidence, etiology, treatment, and long-term outcome. METHODS: Retrospective review of the clinical histories adult patients diagnosed with BJOM (1995-2008) in a tertiary hospital. RESULTS: BJOM was found in 30 of 132 (22.7%) consecutive patients with jaw osteomyelitis. The percentage of BJOM cases increased from 8.7% (4/46) in 1995-2005 to 30.2% (26/86) in 2005-2008. Symptoms appeared in a median of 2.5 years after intravenous use, and 4.5 years after oral exposure. Viridans group streptococci were isolated in 83.3% of cases. Actinomyces spp. was found in 16 (39.0%) of 41 bone histologies. All included patients received a median of 6 months of appropiate antibiotic therapy and a surgical procedure (debridament and/or sequestrectomy). Thirteen of 27 cases (48.1%) with long-term follow-up (median 22 months, IQR 25-75 17-28) failed. Clinical failure defined as, persistent infection or relapse, was more frequent in patients receiving intravenous than oral bisphosphonates (11/16 [68.8%] vs. 2/11 [18.2%]; P < .05) and in cases with Actinomyces spp. (7/10 [70.0%] vs6/17 [35.3%]; P = .08). CONCLUSIONS: Bisphosphonate therapy is now a frequent cause of JO. BJOM is difficult to cure and relapses are common, particularly in patients exposed to intravenous bisphosphonates.

Bone and joint tuberculosis.

INTRODUCTION: Bone and joint tuberculosis has increased in the past two decades in relation with AIDS epidemics. MATERIAL AND METHODS: A literature review of bone and joint tuberculosis, focusing on Pott's disease. RESULTS: Bone and joint TB comprises a group of serious infectious diseases whose incidence has increased in the past two decades, especially in underdeveloped countries, in part due to the AIDS epidemic. Tuberculous spinal infections should be suspected in patients with an insidious, progressive history of back pain and in individuals from an endemic area, especially when the thoracic vertebrae are affected and a pattern of bone destruction with relative disc preservation and paravertebral and epidural soft tissue masses are observed. Atypical tuberculous osteoarticular manifestations involving the extraspinal skeleton, a prosthetic joint, or the trochanteric area, and nontuberculous mycobacterial infections should be considered in favorable epidemiological contexts. Surgery combined with prolonged specific antituberculous chemotherapy is mainly indicated in patients with neurological manifestations or deformities, and provides satisfactory results in most cases. CONCLUSIONS: Spinal tuberculosis is still a relative common extra spinal manifestation of spinal tuberculosis that requires a high degree of suspicion in order to avoid neurological complications and need of surgery.

Clinical experience with daptomycin for the treatment of patients with knee and hip periprosthetic joint infections.

OBJECTIVES: To investigate the clinical efficacy and safety of daptomycin in the treatment of hip and knee periprosthetic joint infections (PJIs). METHODS: We completed a retrospective review of all patients in our institution (n=20) who were treated with daptomycin for hip or knee PJI, over the 36 month period from January 2008 until December 2010. RESULTS: Infection types included eight cases with acute infections, nine cases of chronic infection and three cases of positive intraoperative cultures. Methicillin-resistant coagulase-negative Staphylococcus was the most frequent microorganism found in surgical cultures (40%). Our patients, on average, received daptomycin as salvage therapy at a dose of 6.6 mg/kg/day for 44.9 days. The overall success rate was 78.6% after a median follow-up period of 20 months. In the subgroup of patients with acute PJIs, treatment with daptomycin, debridement and implant retention was successful in all cases. We found two cases of severe side effects (one case of acute renal failure due to massive rhabdomyolysis and one of eosinophilic pneumonia) and two cases of asymptomatic transient creatine phosphokinase (CPK) level elevation. CONCLUSIONS: The combination of high daptomycin doses with an adequate surgical approach could be a viable alternative in cases of difficult-to-treat Gram-positive PJIs. Due to the risk of potentially serious adverse events, serum CPK level should be closely monitored.

[Recurrent urinary tract infections]. / Infecciones urinarias recurrentes.

Recurrent urinary tract infections (RUTI) are a frequent clinical problem in sexually active young women, pregnant or postmenopausal women and in patients with underlying urological abnormalities. The present chapter reviews RUTI based on their classification: relapses, which usually occur early (< 1 month), are caused by the same microorganism and are associated with underlying urological abnormalities, and reinfections, which usually occur later and are caused by a new distinct microorganism (or by the same microorganism usually located in the rectum or uroepithelial cells). The pathogenesis of RUTI is reviewed and the risk factors associated with RUTI in premenopausal women (usually related to sexual activity), postmenopausal women (in whom estrogen deficiency has a significant effect on the vaginal Lactobacillus flora), and in pregnant women are discussed. Likewise, an extensive review of the distinct therapeutic strategies to prevent RUTI is provided: self-treatment of cystitis, continuous antibiotic prophylaxis, postcoital antibiotic prophylaxis, topical vaginal estrogens, Lactobacillus, cranberry juice, intravesical administration of non-virulent E. coli strains and vaccines, among others. Several diagnostic-therapeutic algorithms are included. These algorithms are based on the type of urinary infection (relapse-reinfection), on the type of patient (young, postmenopausal, or pregnant women) and on the number of episodes of RUTI.