Low-risk Staphylococcus aureus bacteremia patients do not require routine diagnostic imaging: A multicenter retrospective cohort study.

BACKGROUND: Risk stratification to categorize patients with Staphylococcus aureus bacteremia (SAB) as low- or high-risk for metastatic infection may direct diagnostic evaluation and enable personalized management. We investigated the frequency of metastatic infections in low-risk SAB patients, their clinical relevance, and whether omission of routine imaging is associated with worse outcomes. METHODS: We performed a retrospective cohort study in seven Dutch hospitals among adult patients with low-risk SAB, defined as hospital-acquired infection without treatment delay, absence of prosthetic material, short duration of bacteremia, and rapid defervescence. The primary outcome was the proportion of patients whose treatment plan changed due to detected metastatic infections, as evaluated by both the actual therapy administered and by linking a retrospectively adjudicated diagnosis to guideline-recommended treatment. Secondary outcomes were 90-day relapse-free survival, and factors associated with performing of diagnostic imaging. RESULTS: Of 377 patients included, 298 (79%) underwent diagnostic imaging. In 15 of these 298 patients (5.0%) imaging findings during patient admission had been interpreted as metastatic infections that should extend duration of treatment. Using the final adjudicated diagnosis, 4 patients (1.3%) had clinically relevant metastatic infection. In a multilevel multivariable logistic regression analysis, 90-days relapse-free survival was similar between patients without imaging and those who underwent imaging (81.0% versus 83.6%; aOR 0.749 (95% CI 0.373-1.504). CONCLUSION: Our study advocates risk stratification for the management of patients with SAB. Prerequisites are follow-up blood cultures, bedside ID consultation, along with critically reviewing disease evolution. Using this approach, routine imaging could be omitted in low-risk patients.

No association between COVID-19 related liver injury and the course of disease: a retrospective study.

OBJECTIVE: Several studies have reported on liver injury during COVID-19. However, the definition and timing of liver injury is different among the published articles. The aim of the present study is to evaluate whether COVID-19 related liver injury at the time of first presentation is associated with the course of the disease. METHODS: We conducted a single center retrospective study at Amphia Hospital in Breda, The Netherlands, from February 1 through April 30, 2020. Patients with reverse transcription polymerase chain reaction confirmed COVID-19 were included. We excluded patients with known chronic liver disease, harmful alcohol consumption or patients on certain antibiotics prior to admission. The clinical characteristics and outcomes of patients with and without COVID-19 related liver injury were compared. Liver injury was defined as elevated alanine aminotransferase and/or alkaline phosphatase at the time when the first positive COVID-19 sample was obtained. RESULTS: We included 382 patients with COVID-19 infection. The incidence of liver injury was 41.6% (n = 159). Being female was associated with liver injury (p < .05). Liver injury was not associated with a more severe course of the disease in terms of hospitalization, length of hospital stay, intensive care unit admission and mortality. CONCLUSION: COVID-19 related liver injury at the time of diagnosis of COVID-19 does not seem to be associated with a more severe course of the disease in our hospital.

[Visual recovery as the target for glaucoma]. / Visuelle Regeneration als Ziel für das Glaukom.

BACKGROUND: Visual recovery is an established but poorly studied phenomenon in glaucoma. OBJECTIVE: To provide insights into functional recovery of retinal ganglion cells (RGCs) with a view to providing information on the development of forms of treatment that improve RGC function after injury. METHOD: A model of recoverable RGC function in the mouse eye, induced by short-term elevation of intraocular pressure (IOP). RESULTS: The RGCs manifest near complete functional recovery after a prolonged period of dysfunction following acute IOP elevation. Increasing age and a high fat diet were subsequently found to impair recovery, whereas exercise substantially improved recovery such that older mice recovered in a similar way to young mice. CONCLUSION: Injured RGCs have the capacity to restore function after periods of functional impairment. Therapies that specifically target injured RGCs and enhance their capacity to recover function may provide a new approach for treating glaucoma.

Spontaneous fracture of the femur due to osteomyelitis caused by the Streptococcus anginosus group.

A 57-year-old man was admitted because of pain in the right upper leg due to an osteolytic lesion of the femoral bone which was complicated by a spontaneous fracture. At first a malignancy was suspected. However, blood and bone cultures revealed the Streptococcus anginosus group. A diagnosis of acute osteomyelitis was made. In spite of extensive antibiotic and surgical treatment the patient developed severe septic shock with multiple organ failure and died. In the case of a pathological fracture, one should consider the broad differential diagnosis, including osteomyelitis, which should lead to a laboratory work-up and imaging studies. When bone biopsy for histological analysis is necessary, a microbiological culture to look for osteomyelitis should always be performed.

[Fever and hypotension after treatment of syphilis; the Jarisch-Herxheimer reaction]. / Koorts en hypotensie na behandeling van syfilis.

A 73-year-old man presented with fever and hypotension, which had developed a few hours after receiving treatment with benzyl-penicillin for secondary syphilis. These symptoms were due to the so-called Jarisch-Herxheimer reaction. The patient was admitted to hospital and treated with prednisone and intravenous fluids. Within 24 hours the patient had fully recovered. The symptoms, pathogenesis and treatment of Jarisch-Herxheimer reaction are discussed.

Targeting retinal ganglion cell recovery.

Accumulating evidence from experimental and clinical studies suggest that retinal ganglion cells at least in the earlier stages of glaucoma have the capacity to recover function following periods of functional loss. The capacity for recovery may be negatively impacted by advancing age but can be boosted by interventions such as diet restriction and exercise.

[A blood culture containing coagulase-negative staphylococci: not always due to contamination]. / Coagulasenegatieve stafylokokken in een bloedkweek.

Staphylococcus lugdunensis (SL) is a species belonging to the group of coagulase-negative staphylococci (CNS). It can cause severe infections such as endocarditis. Three cases of endocarditis caused by SL are presented. The first case describes a 71-year-old man with a fever and endogenous endophthalmitis. The second case describes delirium in an 87-year-old woman, thought to be due to pneumonia. The third case describes a 76-year-old man with an infection of unknown origin. In all cases, the first blood cultures drawn were positive for CNS and considered to be contaminated. However, all three patients were finally diagnosed as having severe endocarditis caused by SL. Two patients underwent valve replacement, one patient died due to ongoing sepsis. The first CNS-positive blood cultures drawn were wrongly denoted as being contaminated. Physicians should be aware of the pathogenic potential of SL and rule out contamination.

Axonal transport along retinal ganglion cells is grossly intact during reduced function post-injury.

It has been established that beyond middle age, mice are slower to recover inner retinal function following an acute intraocular pressure (IOP) injury. While 3 month old animals exhibit near-complete recovery 1 week following injury, 12 and 18 month old animals demonstrate prolonged inner retinal dysfunction. In this study we aim to determine whether age-related differences in functional recovery of the inner retina are due to differences in retinal ganglion cell (RGC) axonal transport. C57BL/6J mice at 3 (n = 8) and 18 months (n = 8) of age were used. At day 0, right eyes were cannulated and the IOP was maintained at 50 mmHg for 30 min. At day 5, mice received bilateral intravitreal injections of choleratoxin subunit B (CTB) conjugated to Alexafluor 488. At day 7, mice were euthanized and tissue was collected. Axonal transport of CTB was quantified in retinas and superior colliculi (SC) using fluorescent microscopy. In response to IOP elevation, the overall degree of axonal transport was comparable between young and old mice. Furthermore, no differences in axonal transport were detected between control eyes and injured in mice at any age. In conclusion, impaired recovery of inner retinal function 1 week following acute IOP injury in old mice is not associated with changes in active axonal transport in RGCs at this time.

MRSA as a rare cause of vaginitis.

We describe a 26-year-old otherwise healthy woman with MRSA vaginitis. Traditional MRSA risk factors were absent and additional screening sites were negative. Patient was treated successfully with oral antibiotics combined with topical lactic acid emulsion. Because her partner appeared to have solitary MRSA carriage on the glans, a suggestion of sexual transmission was made. He was treated successfully with topical mupirocin ointment. Although solitary vaginal MRSA carriage and infection seems to be rare and its clinical impact is yet undefined, clinicians should consider adding the genitourinary tract to traditional screening sites in case of recurrent MRSA infections.

Erectile dysfunction as the presenting symptom of a pheochromocytoma.

We report the case of a 59-year-old man with a pheochromocytoma in which erectile dysfunction was the main symptom. Erectile function was related to the amount of noradrenaline secreted by the tumor, as was determined when recurrence of the malignancy was diagnosed twice. Erectile function could be restored by lowering the level of noradrenaline excretion, either by removal of the noradrenaline-producing tumor or by treatment with doxazosin. By stimulating alpha-1-adrenoceptors, high levels of noradrenaline are likely to result in excessive contraction of the corpus cavernosum and penile vessels and, thereby, cause erectile dysfunction.

Meningococcal pericarditis and tamponade.

We report the case of a 37-year-old female with a complex manifestation of serogroup C meningococcal disease. The patient presented with symptoms and signs of pneumonia, sepsis and diffuse intravascular coagulation. Moreover, she suffered from a culture-proven pyogenic pericarditis that deteriorated into cardiac tamponade. Immediate pericardiocentesis was successful and eventually the patient recovered.

[Hepatocellular carcinoma complicated by non-islet cell tumor hypoglycemia]. / Hepatocellulair carcinoom gecompliceerd door 'non-islet cell tumour hypoglycaemia' (niet-insulinoomhypoglykemie).

A 36-year-old woman presented with right upper quadrant abdominal pain, weight loss and attacks of severe sweating. She was known to have a chronic hepatitis B infection. A large hepatocellular carcinoma was diagnosed complicated by recurrent episodes of hypoglycaemia. Serum insulin, insulin-like growth factor (IGF-I) and growth hormone levels proved to be low, with increased serum levels of big-IGF-II. This is indicative of non-islet cell tumour hypoglycaemia. The patient received prednisone which resulted in an improvement in the blood glucose values but the morning hypoglycaemia remained, so that nightly intravenous glucose administration continued to be necessary. Therefore, growth hormone was added to the treatment which resulted in a complete disappearance of the hypoglycaemias. The patient died within 6 months of the diagnosis having been established.

Tuberculous pleurisy: an unusual complication during treatment of Crohn disease with azathioprine.

A patient is presented with Crohn disease who developed tuberculous pleurisy while treated with azathioprine. The prevalence of opportunistic infections is discussed in patients with inflammatory bowel disease and treated with immunosuppressive regimes.

A patient with gastric fundal varices and colonic varices due to splenic vein thrombosis.

We report a patient presenting with melena. Endoscopic examination showed gastric fundal varices as well as colonic varices. The latter is rarely encountered and is usually associated with portal hypertension. On angiography there appeared to be a splenic vein thrombosis which is only reported once earlier as a cause of colonic varices. A short review of the literature concerning colonic varices is added.