Outbreak of KPC-producing Klebsiella pneumoniae at a Portuguese university hospital: Epidemiological characterization and containment measures.

Background: KPC-producing K pneumoniae (KPC-Kp) is a public health problem with important clinical and epidemiological implications. We describe an outbreak of KPC-Kp at vascular surgery and neurosurgery wards in a central hospital in Porto, Portugal. Methods: A case of KPC-Kp was considered to be a patient positive for KPC-Kp with strong epidemiological plausibility of having acquired this microorganism in the affected wards and/or with genetic relationship ≥92% between KPC-Kp isolates. Active surveillance cultures (ASCs) and real-time polymerase chain reaction were used for the detection of carbapenemase genes through rectal swab in a selected population. Molecular analysis was performed using pulsed-field gel electrophoresis at the National Reference Laboratory. Patient risk factors were collected from the electronic medical record system. Information regarding outbreak containment strategy was collected from the Infection Control Unit records. Results: Of the 16 cases, 11 (69%) were identified through active screening, representing 1.4% of the total 766 ASCs collected. The most frequent risk factors identified were previous admission (63%), antibiotic exposure in the past 6 months (50%), and immunodepression (44%). The length of stay until KPC-Kp detection was high (0-121 days, mean 35.6), as was the total length of stay (5-173 days, mean 56.6). Three patients (19%) were infected by KPC-Kp, 2 of whom died. One previously colonized patient died later because of KPC-Kp infection. Conclusions: Multifactorial strategy based on contact precautions (with patient and healthcare professional cohorts) and ASC, as well as Antibiotic Stewardship Program reinforcement, allowed to contain this KPC-Kp outbreak.

Jaundice as a Rare Manifestation of Epstein-Barr Virus Primary Infection.

Epstein-Barr virus (EBV) primary infection usually presents with classic symptoms of infectious mononucleosis (IM) like fever, lymphadenopathies and tonsillopharyngitis. Liver damage is frequently mild and self-limited and there are only a few cases of severe EBV-induced cholestatic hepatitis and jaundice reported in the literature. The authors present the case of a 22-year-old woman who was admitted with acute fever and jaundice. Physical examination revealed posterior cervical lymphadenopathies and painful hepatosplenomegaly. Laboratorial findings suggested an obstructive cause for jaundice but ultrasound and magnetic resonance cholangiopancreatography excluded biliary duct pathology. Heterophile antibodies were negative but EBV-specific antibodies revealed isolated positive viral capsid antigen (VCA) immunoglobin (Ig) M suggesting the diagnosis of early phase of EBV primary infection. The diagnosis of EBV-induced cholestatic hepatitis was confirmed after identification of EBV deoxyribonucleic acid (DNA) in blood and by liver biopsy. Supportive management was provided and, despite an initial clinical deterioration, the patient had a favorable outcome. EBV is a virus with a high prevalence worldwide, mainly subclinical, and jaundice is a rare manifestation of the infection. Although the majority of the patients recover without sequelae, progression to liver failure has been described and a careful assessment for complications is mandatory. Therefore, EBV infection should be included in the comprehensive differential diagnosis of jaundice in all age groups.

Acute HIV infection presenting as hemophagocytic syndrome with an unusual serological and virological response to ART.

BACKGROUND: HIV clinical presentation in the acute stage is variable and some of its virological and immunological aspects are not completely understood. Most cases of HIV- associated reactive hemophagocytic syndrome have been reported in patients with advanced stages of HIV and to our knowledge, there are only 8 cases in the English literature presenting during acute HIV infection, most in East Asia, being this the first case in a European patient. CASE PRESENTATION: We report a case of a European Caucasian 27- year old woman with a primary HIV- infection presenting with extremely low CD4+ T cell count who developed a haemophagocytic syndrome after starting ART and in whom we documented a very unusual serological and virological response, characterized by an impaired HIV- antibody production and a 12 month time frame to reach an undetectable viral load, despite no evidence of resistance. CONCLUSIONS: This case report apart from describing an unusual clinical presentation of an acute HIV infection as hemophagocytic syndrome provides useful information that might contribute for understanding some subtle issues in acute HIV infection, namely the dynamics of virological and immunological aspects after antiretroviral therapy initiation.

The tuberculin skin test still matters for the screening of latent Tuberculosis infections among Inflammatory Bowel Disease patients.

BACKGROUND AND AIMS: There is a high risk of Tuberculosis among patients medicated with anti-tumour necrosis factor α (anti-TNFα) that can be mitigated by treating latent Tuberculosis infections (LTI). This study aimed to evaluate the performance of Tuberculin Skin test (TST) and Quantiferon-TB Gold in Tube (QFT-GIT) in a population of patients suffering from Inflammatory Bowel Diseases. METHODS: The cohort analyzed in this study consisted of 250 patients, of whom 15% were therapy-naïve and 85% were medicated: 70% under immunosuppressive therapy and 30% on anti-TNFα. A LTBI was diagnosed following a positive result in either of the tests and their performance and concordance were evaluated. RESULTS: Fifty-eight and 24 patients had a positive TST and QFT-GIT, respectively. In 72 (29%) patients LTBI was diagnosed, of whom 8 (21%) were therapy-naïve. TST had an overall higher sensitivity (81% vs. 35%) and a higher Negative Predictive Value (93% vs. 80%) when compared to QFT-GIT test; this superiority was consistently maintained irrespective of the presence and kind of backbone immunosuppressive therapies. The concordance between both tests was weak. CONCLUSIONS: Our results underscore the need to maintain the TST on LTBI diagnosis in patients about to start or switch anti-TNFα therapy in an intermediate Tuberculosis incidence context.

Fungal prosthetic valve endocarditis with mycotic aneurysm: Case report.

Fungal prosthetic valve endocarditis is an extremely severe form of infective endocarditis, with poor prognosis and high mortality despite treatment. Candida albicans is the most common etiological agent for this rare but increasingly frequent condition. We present a case of fungal prosthetic valve endocarditis due to C. albicans following aortic and pulmonary valve replacement in a 38-year-old woman with a history of surgically corrected tetralogy of Fallot, prior infective endocarditis and acute renal failure with need for catheter-based hemodialysis. Antifungal therapy with liposomal amphotericin B was initiated prior to cardiac surgery, in which the bioprostheses were replaced by homografts, providing greater resistance to recurrent infection. During hospitalization, a mycotic aneurysm was diagnosed following an episode of acute arterial ischemia, requiring two vascular surgical interventions. Despite the complications, the patient's outcome was good and she was discharged on suppressive antifungal therapy with oral fluconazole for at least a year. The reported case illustrates multiple risk factors for fungal endocarditis, as well as complications and predictors of poor prognosis, demonstrating its complexity.

Candida parapsilosis prosthetic valve endocarditis.

Candida endocarditis is a rare infection associated with high mortality and morbidity. There are still some controversies about Candida endocarditis treatment, especially about the treatment duration. We report a case of a Candida parapsilosis endocarditis that presented as a lower limb ischemia. The patient was surgically treated with a cryopreserved homograft aortic replacement. We used intravenous fluconazole 800 mg as initial treatment, followed with 12 months of 400 mg fluconazole per os. The patient outcome was good.

A violência psicológica na relação entre professor e aluno com dificuldades de aprendizagem / The psychological violence in the relationship between teacher and student with learning difficulties / La violencia psicológica en la relación entre profesor y estudiantes con dificultades de aprendizaje

Neste trabalho, buscou-se investigar as ações do professor que se caracterizam por violência psicológica no cotidiano escolar. A pesquisa, pautada nas diretrizes epistemológicas da investigação qualitativa, foi realizada em uma escola pública que atende crianças dos anos iniciais do Ensino Fundamental. Os participantes foram quatro crianças e sua professora. Para a coleta dos dados, foram utilizados os seguintes instrumentos: observação com recurso do diário de campo, videogravação e entrevista semiestruturada. As ações identificadas como violência psicológica foram: rejeição, humilhação e indiferença. Observou-se que a escola passou a ser objeto de um temor proveniente de vivências marcadas por ações de segregação, punição e desrespeito à condição dos alunos com dificuldades de aprendizagem e, consequentemente, ao saber dessas crianças que fracassavam nesse importante cenário de seu desenvolvimento.

This research aims to investigate the teacher actions that are characterized psychological violence in school routine. The research, based on epistemological guidelines of qualitative investigation, was realized in a public school that serves children in the early years of the Elementary School. The participants were four children and their teacher. In order to collect data, the following instruments were applied: observation with the use of field notes, video recording and a semi-structured interview. The actions identified as psychological violence were: rejection, humiliation and indifference. In this study, it was possible to notice that school became an object of fear coming from experiences marked by segregation, punishment and non-respect actions towards their conditions, and consequently, by knowing these children failed in so important scenery of their development.

En este trabajo trato investigar las acciones de la profesora que se caracterizan por violencia psicológica en el cotidiano escolar. La pesquisa, pautada en las directrices epistemológicas de la investigación cualitativa, fue realizada en una escuela pública que atiende niños de los años iniciales de la Escuela Primaria. Los participantes fueron cuatro niños y su profesora. Para la coleta de los dados, fueron utilizados los siguientes instrumentos: observación con recurso del diario de campo, videograbación y entrevista semi-estructurada. Las acciones identificadas como violencia psicológica fueron: rechazo, humillación e indiferencia. Observado que la escuela paso a ser objeto de un temor proveniente de vivencias marcadas por acciones de segregación, punición y falta de respeto a la condición de los estudiantes con dificultades de aprendizaje y, consecuentemente al saber de esos niños que fracasaban en ese importante escenario de su desenvolvimiento.