An Atypical Case of Microscopic Polyangiitis Associated With Myelodysplastic Syndrome and Complete Atrioventricular Block Mistaken for Infectious Pneumonia.

The association between antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and hematologic malignancy has been previously described and remains a rare phenomenon (although potentially underdiagnosed). We report the case of an 81-year-old patient with myelodysplastic syndrome who was managed for an infectious-appearing pneumonia, which subsequently complicated into complete heart block and severe acute respiratory distress syndrome with a fatal outcome. The final diagnosis is severe hemorrhagic alveolitis due to ANCA-associated vasculitis meeting the criteria for microscopic polyangiitis. This article provides an opportunity to discuss the association between ANCA-associated vasculitis and hematologic malignancies and the adverse prognosis associated with it.

Long-term outcomes and cardiac surgery in critically ill patients with infective endocarditis.

AIMS: To assess long-term outcomes and the management of critical left-sided infective endocarditis (IE) and evaluate the impact of surgery. METHODS AND RESULTS: Among the 198 patients included prospectively for IE across 33 adult intensive care units (ICU) in France from 1 April 2007 to 1 October 2008, 137 (69%) were dead at a median follow-up time of 59.5 months. Characteristics significantly associated with mortality were: Sepsis-related Organ-Failure Assessment (SOFA) score at ICU admission [Hazard ratio (HR), 95% Confidence Interval (CI) of 1.43 (0.79-2.59) for SOFA 5-9; 2.01 (1.05-3.85) for SOFA 10-14; 3.53 (1.75-7.11) for SOFA 15-20; reference category SOFA 0-4; P = 0.003]; prosthetic mechanical valve IE [HR 2.01; 95% CI 1.09-3.69, P = 0.025]; vegetation size ≥15 mm [HR 1.64; 95% CI 1.03-2.63, P = 0.038]; and cardiac surgery [HR (95%CI), 0.33 (0.16-0.67) for surgery ≤1 day after IE diagnosis; 0.61 (0.29-1.26) for surgery 2-7 days after IE diagnosis; 0.42 (0.21-0.83) for surgery >7 days after IE diagnosis; reference category no surgery; P = 0.005]. One hundred and three (52%) patients underwent cardiac surgery after a median time of 6 (16) days. Independent predictors of surgical intervention on multivariate analysis were: age ≤60 years [Odds ratio (OR) 5.30; 95% CI (2.46-11.41), P < 0.01], heart failure [OR 3.27; 95% CI (1.03-10.35), P = 0.04], cardiogenic shock [OR 3.31; 95% CI (1.47-7.46), P = 0.004], septic shock [OR 0.25; 95% CI (0.11-0.59), P = 0.002], immunosuppression [OR 0.15; 95% CI (0.04-0.55), P = 0.004], and diagnosis before or within 24 h of ICU admission [OR 2.81; 95% CI (1.14-6.95), P = 0.025]. SOFA score calculated the day of surgery was the only independently associated factor with long-term mortality [HR (95% CI) 1.59 (0.77-3.28) for SOFA 5-9; 3.56 (1.71-7.38) for SOFA 10-14; 11.58 (4.02-33.35) for SOFA 15-20; reference category SOFA 0-4; P < 0.0001]. Surgical timing was not associated with post-operative outcomes. Of the 158 patients with a theoretical indication for surgery, the 58 deemed not fit had a 95% mortality rate. CONCLUSION: Mortality in patients with critical IE remains unacceptably high. Factors associated with long-term outcomes are the severity of multiorgan failure, prosthetic mechanical valve IE, vegetation size ≥15 mm, and surgical treatment. Up to one-third of potential candidates do not undergo surgery and these patients experience extremely high mortality rates. The strongest independent predictor of post-operative mortality is the pre-operative multiorgan failure score while surgical timing does not seem to impact on outcomes.

Fatal peritonitis caused by Rhizopus microsporus.

A 52-year-old woman with a history of Crohn's disease was admitted due to peritonitis which followed an intestinal perforation. After transitory treatment with voriconazole, resolution of the infection was complicated by recurring peritonitis resulting from necrosis and perforation of the left colon which ultimately lead to the death of the patient. Microscopic examination of the peritoneal fluid revealed the presence of broad, irregular hyphae and culture of the fluid yielded Rhizopus microsporus. The identification of the fungus was confirmed by its characteristic microscopic morphology and sequencing of the ITS region of the rDNA. The histopathologic examination of the colon tissue demonstrated the presence of broad, non-septate hyphae and the same fungus was again isolated in culture.

Native-valve infective endocarditis caused by Enterobacteriaceae: report on 9 cases and literature review.

Although the demographic characteristics of patients who develop infective endocarditis (IE) have changed over the last few decades, Enterobacteriaceae remain rarely responsible. We report the clinical and epidemiological characteristics of 9 patients with native-valve Enterobacteriaceae IE from 6 French medical intensive care units over a 10-y period and have identified 29 additional cases in the literature. Nearly a third of the 38 patients were immunocompromised and/or had previously known valvular heart disease. Salmonella spp. and Yersinia spp. were the most frequently isolated microorganisms reported in the literature. The overall mortality rate was 24% (9/38) and was lower for operated patients (10% (1/10)) compared to those who did not undergo valve surgery (31% (8/26)). Our results confirmed the rarity of native-valve endocarditis caused by Enterobacteriaceae, pathogens frequently responsible for nosocomial and community-acquired bacteraemias. This paradox may be explained by susceptibility to the bactericidal action of serum and the inability of these bacteria to colonize the endocardium.

Fatal varicella hepatitis in an asthmatic adult after short-term corticosteroid treatment.

A 28-year-old male patient, treated with prednisone for bronchitis with sibilant rales, developed fever with abdominal pain and generalized vesicular rash after coming in contact with varicella-infected children. He was hospitalized after having a seizure. Laboratory values revealed hepatitis and rapidly fulminant hepatic insufficiency with disseminated intravascular coagulation. Despite acyclovir treatment, the patient died 4 days after admission. Clinical presentation could evoke a Reye's syndrome, but liver biopsy showed massive coagulative necrosis. This report demonstrates the increased risk of complicated varicella associated with the use of corticosteroids, even for a short period of time.