Relationship among Streptococcus gallolyticus Subsp. gallolyticus, Enterococcus faecalis and Colorectal Neoplasms in Recurrent Endocarditis: A Historical Case Series.

OBJECTIVES: The role of colorectal neoplasms (CRN) as a common potential source of recurrent Streptococcus gallolyticus subsp. gallolyticus (SGG) and Enterococcus faecalis (EF) endocarditis remains unstudied. We aimed to investigate what proportion of episodes of recurrent endocarditis are caused by a succession of SGG and EF, or vice versa, and to assess the role of a colonic source in such recurrent episodes. METHODS: we conducted a retrospective analysis of two prospective endocarditis cohorts (1979-2019) from two Spanish hospitals, providing descriptive analyses of the major features of the endocarditis episodes, colonoscopy findings, and histologic results. RESULTS: among 1552 IE episodes, 204 (13.1%) were caused by EF and 197 (12.7%) by SGG, respectively. There were 155 episodes (10%) of recurrent IE, 20 of which (12.9%) were due to a succession of SGG/EF IE in 10 patients (the first episode caused by SGG in eight cases, and by EF in two cases). The median follow-up was 86 (interquartile range 34-156) months. In 8/10 initial episodes, the causative microorganism was SGG, and all patients were diagnosed with CRN either during the initial episode or during follow-up. During the second episode of IE or follow-up, colonoscopies revealed CRN in six patients. CONCLUSIONS: There seems to be an association between SGG and EF in recurrent endocarditis that warrants further investigation. Our findings reinforce the need for systematically performing colonoscopy in the event of endocarditis caused by both microorganisms.

Usefulness of a Telemedicine Tool TELEA in the Management of the COVID-19 Pandemic.

Background: The usefulness of telemedicine in the management of the coronavirus disease 2019 (COVID-19) pandemic has not been evaluated. Methods: We conducted a descriptive study of the process of recruitment and follow-up of patients using a telemedicine tool (TELEA) in the management of patients at risk, in a rural environment with a dispersed population in Lugo in north western Spain. Results: A large number of patients diagnosed with COVID-19 infection (N = 545) were evaluated. Of this group, 275 had comorbidities and were enrolled in the program, with a mean age of 57.6 ± 16.3 years, 43.1% male. The risk factors were hypertension (38%), diabetes (16%), asthma (9.5%), heart disease (8.8%), and immunosuppression (5.1%). Patients were followed through the platform with daily control of symptoms and vital signs. Only 8% were admitted to the hospital, 5.1% on a scheduled basis and 2.9% through the emergency room. Conclusion: The telemedicine tool TELEA is useful for the management of high-risk patients with COVID-19.

Colorectal neoplasm in cases of Clostridium septicum and Streptococcus gallolyticus subsp. gallolyticus bacteraemia.

BACKGROUND: Bacteremia with Clostridium septicum (CS) and Streptococcus gallolyticus subsp. gallolyticus (SGG) have both been associated with colorectal neoplasms (CRN) and colonoscopic examination is advised, however the differences and similarities in colorectal findings are not well known. METHODS: This is a multicenter, comparative study of patients with CS bacteremia [44 of 664 cases (6.6%) of Clostridium spp.] and SGG bacteremia [257 of 596 cases (44.2%) of S. bovis group], carried out in three hospitals from Spain. Clinical findings related to bacteremia and associated CRN were collected. RESULTS: The main sources of infection were abdominal (77.7%) for CS bacteremia and endovascular (75%) for SGG bacteremia. CS bacteremia was more often associated with malignancies, (72.6% vs. 19.4%) and neutropenia (29.5% vs. 3.1%), and was more acute, with shock at presentation (63.6% vs. 3.9%) and higher 30-day mortality (47.7% vs. 9.7%) compared to SGG (P<0.05 for all). Both, patients with CS and SGG bacteremia often had concomitant CRN (43.1% vs. 49.8%) and most of them presented as occult CRN (73.7% vs. 91.4%; P=0.02). CS cases more often had invasive carcinomas (94.7% vs. 19.5%), location of CRN in the right colon (73.7% vs. 23.4%), larger tumor size (median 7 vs. 1.5cm), and a higher overall CRN related mortality rate (68.4% vs. 7.8%) compared to SGG cases (P<0.05 for all). CONCLUSIONS: Both, CS and SGG bacteremia are associated with occult CRN. CS cases more often had advanced carcinomas than SGG cases, suggesting a distinct temporal association with CRN.

Relationship Between Enterococcus faecalis Infective Endocarditis and Colorectal Neoplasm: Preliminary Results From a Cohort of 154 Patients.

INTRODUCTION AND OBJECTIVES: The association between Streptococcus bovis group infective endocarditis and colorectal neoplasm (CRN) is well-known. However, no studies have assessed the association between Enterococcus faecalis infective endocarditis (EFIE) and CRN. We aimed to determine whether the prevalence of CRN is higher in patients with EFIE and an unclear source of infection than in patients with EFIE and a known source of infection or in the general population. METHODS: Retrospective analysis of a cohort of 154 patients with definite EFIE (109 with an unclear source of infection and 45 with an identified source) from 2 Spanish teaching hospitals to determine the prevalence of CRN and other colorectal diseases. RESULTS: In the group with an unknown source of infection, 61 patients (56%) underwent colonoscopy; of these, 31 (50.8%) had CRN. Nonadvanced colorectal adenoma was detected in 22 patients (36%), advanced adenoma in 5 (8.2%), and colorectal carcinoma (CRC) in 4 (6.6%). Among patients who survived the EFIE episode with ≥ 2 years of follow-up, 1 case of CRC was subsequently diagnosed. Only 6 patients (13.3%) with an identified focus of infection underwent colonoscopy; 1 of these patients (16.7%) was diagnosed with CRN. The prevalence of adenomas was slightly higher than that of the Spanish population in the same age range, whereas that of CRC was 17-fold higher. CONCLUSIONS: CRN was found in more than half of patients with EFIE and an unclear focus of infection who underwent colonoscopy. Colonoscopy should be recommended in patients with EFIE and an unclear source of infection.

Streptococcus bovis septic arthritis and osteomyelitis: A report of 21 cases and a literature review.

BACKGROUND: The Streptococcus bovis group (SBG) is a well-known cause of endocarditis, but its role in osteoarticular infections (OAIs) has not been well described. METHODS: We analyzed all patients with OAIs by SBG diagnosed in our hospital (1988-2014). We selected those cases with septic arthritis and osteomyelitis, as defined according to clinical, microbiological, and imaging studies. Identification of the strains was performed by using the API 20 Strep and the GP card of the Vitek 2 system, and confirmed the identification by molecular methods. In addition, we reviewed the literature to select all cases of OAI by SBG during the period 1980-2015. RESULTS: From the 83 cases of OAI included in the analysis (21 from our center and 62 from the literature review), 59 were osteomyelitis (57 of them spondylodiscitis) and 24 were arthritis (2 with associated spondylodiscitis). The mean age was 66.9 years, and 79.2% of the patients were men. Endocarditis (IE) was associated with 59% of the cases and this association was greater for osteomyelitis than for arthritis (78.9% vs. 13.6%; P = 0.001). OAI was a presenting symptom in 63% of the cases of IE. Colonoscopy was performed in 64 cases, which detected colorectal neoplasm (CRN) in 46 patients (71.8%), almost all asymptomatic. Some 69.5% of these neoplasm were carcinomas or advanced adenomas. The blood cultures were positive in 78.3% cases. In 45 cases, the S. bovis species was identified; in 82.2% of the cases the cause was Streptococcus gallolyticus subsp. gallolyticus. The mortality was 7.2%, which in no case was attributable to the OAI. CONCLUSIONS: OAIs are frequently the initial manifestation of IE caused by SBG. S. gallolyticus causes most of these infections. Echocardiogram and colonoscopy are therefore mandatory, given the species' close association with IE and CRN.

The clinical epidemiology and malignancies associated with Streptococcus bovis biotypes in 506 cases of bloodstream infections.

OBJECTIVES: To determine the incidence of Streptococcus bovis (Sb) biotypes causing bacteraemia and associated malignancies. METHODS: This is a retrospective analysis of patients with Sb bacteraemia, pulled out from a prospective surveillance protocol of bacteraemia cases, in three areas of Spain (1990-2013): a cattle area (Lugo), a fishing area (Ferrol) and an urban area (Barcelona). Colonoscopy and Sb biotypes (Sb-I and Sb-II) were determined in most cases. RESULTS: 506 patients with Sb bacteraemia; mean age 68.1 (±14.1) years, and 66.2% were males. The cattle area, compared with the fishing and urban areas, had higher incidence of bacteraemia by SbI (40.29 vs 9.38 vs 6.15 cases/10(6) person-years, P < 0.001) and bacteraemia by Sb-II (29.07 vs 9.84 vs 13.37 cases/10(6) person-years, P < 0.001). The Sb-I cases (n = 224), compared with Sb-II cases (n = 270), had greater rates of endocarditis (77.6% vs 9.6%, P < 0.001) and colorectal neoplasm (CRN) (50.9% vs 16.6%, P < 0.001), and smaller rates of biliary tract infection (2.2% vs 29.6%, P < 0.001) and non-colorectal malignancy (8.9% vs 31.4%, P < 0.001). CONCLUSION: There was a link between the cattle area and higher incidence of Sb bacteraemia. Sb-I differed from Sb-II cases in clinical findings and associated malignancies. Colonoscopy is mandatory in cases of endocarditis or bacteraemia caused by Sb-I.

Prognostic significance of multidetector CT in normotensive patients with pulmonary embolism: results of the protect study.

BACKGROUND: In patients with acute pulmonary embolism (PE), rapid and accurate risk assessment is paramount in selecting the appropriate treatment strategy. The prognostic value of right ventricular dysfunction (RVD) assessed by multidetector CT (MDCT) in normotensive patients with PE has lacked adequate validation. METHODS: The study defined MDCT-assessed RVD as a ratio of the RV to the left ventricle short axis diameter greater than 0.9. Outcomes assessed through 30 days after the diagnosis of PE included all-cause mortality and 'complicated course', which consisted of death from any cause, haemodynamic collapse or recurrent PE. RESULTS: MDCT detected RVD in 533 (63%) of the 848 enrolled patients. Those with RVD on MDCT more frequently had echocardiographic RVD (31%) than those without RVD on MDCT (9.2%) (p<0.001). Patients with RVD on MDCT had significantly higher brain natriuretic peptide (269±447 vs 180±457 pg/ml, p<0.001) and troponin (0.10±0.43 vs 0.03±0.24 ng/ml, p=0.001) levels in comparison with those without RVD on MDCT. During follow-up, death occurred in 25 patients with and in 13 patients without RVD on MDCT (4.7% vs 4.3%; p=0.93). Those with and those without RVD on MDCT had a similar frequency of complicated course (3.9% vs 2.3%; p=0.30). CONCLUSIONS: The PROgnosTic valuE of CT study showed a relationship between RVD assessed by MDCT and other markers of cardiac dysfunction around the time of PE diagnosis, but did not demonstrate an association between MDCT-RVD and prognosis.

Association between bacteremia due to Streptococcus gallolyticus subsp. gallolyticus (Streptococcus bovis I) and colorectal neoplasia: a case-control study.

BACKGROUND: The association between bacteremia by Streptococcus gallolyticus subsp. gallolyticus (SGG) and colorectal neoplasia (CRN) is well established but the frequency of the association varies widely in different studies. We conducted a case-control study to assess the association between SGG bacteremia and CRN. METHODS: An analysis of all SGG bacteremias was performed during the period 1988-2011. The frequency of CRN in patients with SGG bacteremia was compared with the frequency of CRN in a symptomatic control group of patients matched at a 1:2 ratio for gender and age (±3 years) without S. bovis bacteremia and personal history of CRN and with increased risk of CRN (by the presence of symptoms, signs, or test suspicious of colonic pathology or by family history of CRN). RESULTS: One hundred nine cases of SGG bacteremia were detected (mean age, 66 years; 87% male). Colonoscopy was performed in 98 cases, diagnosing 69 cases of CRN: 57 adenomas (39 advanced adenomas) and 12 invasive carcinomas. Only 4 cases had suspected CRN before the blood culture. The prevalence of CRN was higher in patients with SGG bacteremia than in the 196 control patients (70% vs 32%; odds ratio [OR], 5.1; 95% confidence interval [CI], 3.0-8.6). This difference was not significant when comparing nonadvanced adenomas (19% vs 12%), but we found significant differences in advanced adenomas (40% vs 16%; OR, 3.5; 95% CI, 2.0-6.1) and invasive carcinomas (12% vs 5%; OR, 2.9; 95% CI, 1.2-6.9). CONCLUSIONS: The frequency of CRN among SGG infected patients is significantly increased compared with symptomatic age-matched controls, indicating that SGG infection is a strong indicator for underlying occult malignancy.

Long-term therapy with low-molecular-weight heparin in cancer patients with venous thromboembolism.

Long-term therapy with low-molecular-weight heparin (LMWH) is the treatment of choice for cancer patients with venous thromboembolism (VTE). However, the ideal doses of LMWH have not been thoroughly studied. We used the RIETE Registry data to assess the influence of the daily LMWH dosage on outcome during the first three months after VTE. We used propensity score-matching to compare patients who received <150 vs. those receiving ≥150 UI/kg/day LMWH. Up to July 2010, 3,222 cancer patients with VTE received long-term therapy with fixed doses of LMWH. Of these, 1,472 (46%) received <150 IU/kg/day (mean, 112 ± 28), and 1,750 received ≥150 IU/kg/day (mean, 184 ± 32). Results of the propensity score matching involved 1269 matched pairs. During follow-up, the incidence of pulmonary embolism (PE) recurrences was similar (1.2% vs. 1.9%), but patients receiving <150 IU/kg/day LMWH had a lower incidence of fatal PE than those treated with ≥150 IU/kg/day (0.2% vs. 1.0%; p=0.004). Multivariate analysis confirmed that patients receiving <150 IU/kg/day LMWH had a lower risk for fatal PE (odds ratio [OR]: 0.2; 95% confidence interval [CI]: 0.06-0.8) and for major bleeding (OR: 0.6; 95% CI: 0.3-1.0) than those treated with ≥150 IU/kg/day. In real life, one in every two cancer patients with VTE received lower doses of LMWH than those used in randomised trials, with large variations from patient to patient. Unexpectedly, patients treated with <150 IU/kg/day LMWH had fewer fatal PE cases and fewer major bleeding events than those receiving ≥150 IU/kg/day LMWH. This finding, however, should be validated in prospective clinical trials.

Co-infection by Streptococcus anginosus and Mycobacterium tuberculosis: three case reports.

INTRODUCTION: Bacterial infections may appear as sequelae of remote tuberculous infections, especially thoracic infections. The simultaneous appearance of tuberculosis and bacterial infection is not common, and, to our knowledge, the association of infection by Streptococcus anginosus and Mycobacterium tuberculosis has not been reported previously in the literature. CASE PRESENTATION: We report three cases of dual infection with Streptococcus anginosus and Mycobacterium tuberculosis that were first diagnosed as pyogenic abscesses because of an isolation of Streptococcus anginosus. Despite a course of antibiotics and drainage, the outcome of this initial treatment was unfavourable. A re-evaluation yielded a diagnosis of mixed infection with Streptococcus anginosus and Mycobacterium tuberculosis. CONCLUSION: In a geographical area with a high prevalence of tuberculous disease, the rare possibility of dual infection with Streptococcus anginosus and Mycobacterium tuberculosis should be considered.

Clinical outcome of patients with venous thromboembolism and renal insufficiency. Findings from the RIETE registry.

There is little information on the clinical outcome of patients with venous thromboembolism and renal insufficiency. RIETE is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE). In this analysis we analyzed the three-month outcome in patients with creatinine clearance (CrCl) <30 ml/min. As of March 2007, 1,037 of the 18,251 (5.7%) patients enrolled in RIETE had CrCl <30 ml/min. During the three-month study period these patients had an increased incidence of fatal bleeding, fatal PE, and overall death compared to those with CrCl >30 ml/min. Of the 579 patients presenting with clinically overt PE, 52 (9.0%) died of the initial PE, 13 (2.2%) of recurrent PE, and nine (1.6%) died of bleeding complications. During the first 15 days of therapy the 10% incidence of fatal PE was 10-fold their 1.0% of fatal bleeding. From day 16 to 90, the 1.0% rate of fatal PE was not significantly higher than the 0.5% of fatal bleeding. Of the 458 DVT patients with CrCl <30 ml/min, 14 (3.1%) had fatal bleeding and only one (0.2%) died of PE. In patients with CrCl <30 ml/min presenting with clinically overt PE the main threat is PE itself. On the contrary, in those with DVT the main threat is bleeding.

Pulmonary embolism in patients with chronic obstructive pulmonary disease or congestive heart failure.

BACKGROUND: The diagnosis of pulmonary embolism (PE) is often unreliable in patients with chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). SUBJECTS AND METHODS: Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) is an ongoing registry of consecutive patients with acute venous thromboembolism. In this study, the clinical characteristics, laboratory findings, and clinical outcomes of all enrolled patients with acute PE, with or without underlying cardiopulmonary diseases, were compared and contrasted. In addition, the performance of 2 clinical models for the diagnosis of PE was retrospectively evaluated. RESULTS: As of January 2005, 4444 patients with symptomatic PE have been enrolled in RIETE. Of those, 632 patients (14%) had COPD and 422 (9.5%) had CHF. Significant differences were found in clinical presentation and 3-month outcomes among the 3 groups. With the Geneva model, there was a lower percentage of PE patients with COPD (relative risk [RR] 0.82; 95% confidence interval [CI], 0.66-1.02) or CHF (RR 0.73; 95% CI, 0.56-0.95) who fell into the low pretest probability category, compared with patients with neither. Besides, the percentage of patients with high probability of PE was similar among the 3 patient groups. The frequency of COPD (61%) and CHF (72%) patients with a high pretest probability for PE increased when using the Pisa score, but the percentage of COPD patients into the high probability group was lower (RR 0.60; 95% CI, 0.51-0.71). CONCLUSIONS: Significant differences exist in PE patients with and without underlying cardiopulmonary diseases. The performance of the 2 clinical prediction models varied according to the presence or absence of underlying COPD or CHF.

Presentation and prognosis of gastric cancer in patients aged 80 years and older.

The aim of this study was to analyze the characteristics of the presentation and prognosis of patients aged >/= 80 who were diagnosed with gastric adenocarcinoma. We have used a retrospective cohort study of 2334 patients diagnosed between 1975 and 1993 in northwestern Spain, 263 (11.3%)of whom were >/= 80 years of age. No differences were observed with respect to patients of a younger age at diagnosis regarding the site of the tumor, extension of the disease, or Laurén's histologic type. However, fewer resections with curative intent were performed in the older group (49.1% vs. 30.1%; p < 0.0001). Among those operated on with curative or palliative intent, at the end of the first month the survival probability was 0.9 and the 0.95% confidence interval (CI 95%) was 0.93-0.97 for patients < 80 years of age and 0.93 (CI 95% 0.89-0.98) for the older group ( p = 0.19). At the end of 5 years of follow-up these probabilities were 0.29 (CI 95% 0.27-0.31) and 0.18 (CI 95% 0.14-0.23), respectively ( p < 0.0001). If we consider only those patients undergoing curative resection, the survival probability for the two groups ( p = 0.4) was not statistically different. In conclusion, although the two groups showed similar characteristics at presentation, patients >/= 80 years of age underwent surgery with curative intent less frequently and their general prognosis was worse. Our data support the idea that curative surgery should not be ruled out exclusively for reasons of age.