RESUMEN
We present the case of a recurrent hyperammonaemic encephalopathy due to a portosystemic shunt that was successfully treated by embolization.
Asunto(s)
Embolización Terapéutica/métodos , Encefalopatía Hepática/diagnóstico por imagen , Encefalopatía Hepática/terapia , Hiperamonemia/diagnóstico por imagen , Hiperamonemia/terapia , Anciano , Cirugía Bariátrica/efectos adversos , Femenino , Humanos , Enfermedad del Hígado Graso no Alcohólico/complicaciones , Enfermedad del Hígado Graso no Alcohólico/diagnóstico por imagen , Derivación Portosistémica Quirúrgica , Tomografía Computarizada por Rayos XAsunto(s)
Antiinflamatorios no Esteroideos/efectos adversos , Fiebre/inducido químicamente , Mesalamina/efectos adversos , Corticoesteroides/uso terapéutico , Antibacterianos/uso terapéutico , Antiinflamatorios no Esteroideos/uso terapéutico , Enfermedad de Crohn/tratamiento farmacológico , Femenino , Fiebre/terapia , Fluidoterapia , Humanos , Mesalamina/uso terapéutico , Persona de Mediana Edad , Norepinefrina/uso terapéutico , Sacroileítis/tratamiento farmacológicoRESUMEN
BACKGROUND: The objective of this study is to analyze the factors that are associated with the adequacy of empirical antibiotic therapy and its impact in mortality in a large cohort of patients with extended-spectrum ß-lactamase (ESBL)--producing Escherichia coli and Klebsiella spp. bacteremia. METHODS: Cases of ESBL producing Enterobacteriaceae (ESBL-E) bacteremia collected from 2003 through 2008 in 19 hospitals in Spain. Statistical analysis was performed using multivariate logistic regression. RESULTS: We analyzed 387 cases ESBL-E bloodstream infections. The main sources of bacteremia were urinary tract (55.3%), biliary tract (12.7%), intra-abdominal (8.8%) and unknown origin (9.6%). Among all the 387 episodes, E. coli was isolated from blood cultures in 343 and in 45.71% the ESBL-E was multidrug resistant. Empirical antibiotic treatment was adequate in 48.8% of the cases and the in hospital mortality was 20.9%. In a multivariate analysis adequacy was a risk factor for death [adjusted OR (95% CI): 0.39 (0.31-0.97); P = 0.04], but not in patients without severe sepsis or shock. The class of antibiotic used empirically was not associated with prognosis in adequately treated patients. CONCLUSION: ESBL-E bacteremia has a relatively high mortality that is partly related with a low adequacy of empirical antibiotic treatment. In selected subgroups the relevance of the adequacy of empirical therapy is limited.
Asunto(s)
Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Infecciones por Escherichia coli/tratamiento farmacológico , Escherichia coli/enzimología , Infecciones por Klebsiella/tratamiento farmacológico , Klebsiella/enzimología , beta-Lactamasas/metabolismo , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Bacteriemia/microbiología , Bacteriemia/mortalidad , Niño , Preescolar , Estudios de Cohortes , Escherichia coli/aislamiento & purificación , Infecciones por Escherichia coli/microbiología , Infecciones por Escherichia coli/mortalidad , Femenino , Humanos , Lactante , Recién Nacido , Klebsiella/aislamiento & purificación , Infecciones por Klebsiella/microbiología , Infecciones por Klebsiella/mortalidad , Masculino , Persona de Mediana Edad , España , Análisis de Supervivencia , Resultado del Tratamiento , Adulto JovenAsunto(s)
Tumores Fibrosos Solitarios/diagnóstico por imagen , Neoplasias Gástricas/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Anciano , Enfermedades Asintomáticas , Humanos , Hallazgos Incidentales , Laparoscopía , Masculino , Tumores Fibrosos Solitarios/patología , Tumores Fibrosos Solitarios/cirugía , Neoplasias Gástricas/patología , Neoplasias Gástricas/cirugíaAsunto(s)
Antibacterianos/uso terapéutico , Ceftriaxona/uso terapéutico , Endocarditis Bacteriana/tratamiento farmacológico , Enfermedades de las Válvulas Cardíacas/tratamiento farmacológico , Enfermedades de las Válvulas Cardíacas/microbiología , Válvula Mitral , Infecciones por Salmonella/tratamiento farmacológico , Salmonella enteritidis , Anciano de 80 o más Años , Humanos , Masculino , Inducción de RemisiónAsunto(s)
Insuficiencia Respiratoria , Telangiectasia Hemorrágica Hereditaria , Humanos , Telangiectasia Hemorrágica Hereditaria/complicaciones , Telangiectasia Hemorrágica Hereditaria/diagnóstico , Telangiectasia Hemorrágica Hereditaria/genética , Mutación , Insuficiencia Respiratoria/etiología , Endoglina/genéticaRESUMEN
We present a case of tuberculous peritonitis in a 71-year-old woman with long-standing rheumatoid arthritis treated with adalimumab, and we review the association between antitumor necrosis factor therapy and tuberculosis. Our case illustrates that the index of suspicion of tuberculosis in these patients, even with atypical clinical features, must be very high, and underscores the need of tuberculosis screening before therapy is started.
Asunto(s)
Antiinflamatorios/efectos adversos , Anticuerpos Monoclonales/efectos adversos , Peritonitis/microbiología , Tuberculosis/inducido químicamente , Adalimumab , Anciano , Anticuerpos Monoclonales Humanizados , Artritis Reumatoide/tratamiento farmacológico , Femenino , Humanos , Factor de Necrosis Tumoral alfa/antagonistas & inhibidoresRESUMEN
Although pericardial involvement is very frequent in systemic lupus erythematosus, cardiac tamponade is extremely rare as the first manifestation of the disease. On the other hand, systemic lupus erythematosus is a disease that predominantly affects young women, and it is a very uncommon condition in the elderly. We report a 91-year-old woman diagnosed with cardiac tamponade, which was the presenting clinical feature of a previously undiagnosed case of systemic lupus erythematosus.
Asunto(s)
Taponamiento Cardíaco/etiología , Lupus Eritematoso Sistémico/complicaciones , Lupus Eritematoso Sistémico/diagnóstico , Edad de Inicio , Anciano de 80 o más Años , Taponamiento Cardíaco/inmunología , Diagnóstico Diferencial , Femenino , HumanosAsunto(s)
Antiinflamatorios no Esteroideos/efectos adversos , Dolor de Espalda/tratamiento farmacológico , Enfermedad Hepática Inducida por Sustancias y Drogas/diagnóstico , Hepatitis Autoinmune/diagnóstico , Tiazinas/efectos adversos , Tiazoles/efectos adversos , Citoesqueleto de Actina/inmunología , Alanina Transaminasa/sangre , Antiinflamatorios/uso terapéutico , Antiinflamatorios no Esteroideos/uso terapéutico , Aspartato Aminotransferasas/sangre , Azatioprina/uso terapéutico , Bilirrubina/sangre , Enfermedad Hepática Inducida por Sustancias y Drogas/tratamiento farmacológico , Quimioterapia Combinada , Hepatitis Autoinmune/tratamiento farmacológico , Humanos , Inmunoglobulina G/sangre , Inmunosupresores/uso terapéutico , Masculino , Meloxicam , Persona de Mediana Edad , Prednisona/uso terapéutico , Tiazinas/uso terapéutico , Tiazoles/uso terapéuticoRESUMEN
Microscopic pulmonary tumour embolism is a rare cause of pulmonary hypertension. In most of the reported cases, symptoms develop over several days or weeks in patients previously diagnosed with malignant diseases. In our case, a 41-year-old man with an unremarkable medical history presented with respiratory failure that led to death less than 48 h from the onset of symptoms. Autopsy revealed massive microscopic pulmonary tumour embolism and a multifocal hepatocellular carcinoma. This case report is exceptional because it describes a very rapid clinical progression, and because acute cor pulmonale was the first manifestation of a previously undiagnosed neoplastic disease.
Asunto(s)
Carcinoma Hepatocelular/complicaciones , Neoplasias Hepáticas/complicaciones , Células Neoplásicas Circulantes , Embolia Pulmonar/etiología , Enfermedad Cardiopulmonar/etiología , Enfermedad Aguda , Adulto , Carcinoma Hepatocelular/diagnóstico , Humanos , Neoplasias Hepáticas/diagnóstico , Pulmón/patología , Masculino , Embolia Pulmonar/patología , Enfermedad Cardiopulmonar/patologíaRESUMEN
BACKGROUND AND OBJECTIVE: Clinical suspicion of bacteremia lacks of sensitivity, specificity or predictive values enough to be clinically useful. The aim of this study was to develop a clinical prediction rule of bacteremia for patients hospitalized in an internal medicine department, with community-acquired symptoms, who had blood cultures obtained. PATIENTS AND METHOD: A prospective study, including all patients who had blood cultures in the first 48 h after admission, was performed. A clinical prediction rule of bacteremia was derived from a random sample of two thirds of the patients (derivation cohort) and validated in the remaining (validation cohort). After bivariate analysis, significant variables were included in a stepwise logistic regression analysis. In every patient out of the derivation and validation cohorts a score, derived from the addition of points for each of the significant predictor variables of logistic regression, was obtained; according to this score, 4 groups were formed, and the prevalence of bacteremia in each of them was calculated. Calibration and discrimination were evaluated by the Hosmer-Lemeshow test and area under the ROC curve respectively. RESULTS: Four hundred and forty-eight blood cultures were obtained; the prevalence of bacteremia was 25.2%. Independent predictors of bacteremia in the bivariate analysis were urinary focus of infection, body temperature >= 38.3 degrees C, presence of band forms, ESR >= 70 mm, platelets < 200 * 103/microl, blood glucose >= 140 mg/dl, urea >= 50 mg/dl, C-reactive protein >= 12 mg/dl, and albumin < 3 g/dl. According to the score, in the derivation cohort, four groups with increasing prevalence of bacteremia were identified; in the group with a score between 0 and 3, the prevalence was 2.4%; between 4 and 5: 15.7%; between 6 and 7: 42.9%; and score >= 8: 65%. In the validation cohort, the prevalence was 4.1%, 22.6%, 29.3%, and 80%, respectively. The model showed good calibration (Hosmer-Lemeshow *2 = 4.91; p = 0.77). Area under the ROC curve was 0.81 (95% confidence interval, 0.76-0.86) in the derivation cohort, and 0.77 (95% confidence interval, 0.69-0.85) in validation cohort. CONCLUSIONS: Our model, constructed with 9 variables and a simple additive point system, had good calibration and discrimination, which points at its usefulness to estimate the probability of bacteremia in patients admitted in an Internal Medicine department. Used in conjunction with clinical judgement, the model can be useful in the decision-making process, concerning blood cultures obtention, clinical monitoring, and empirical antimicrobial therapy. Before application, additional prospective validation in other settings is warranted.
Asunto(s)
Bacteriemia/diagnóstico , Infecciones Comunitarias Adquiridas/diagnóstico , Modelos Estadísticos , Anciano , Bacteriemia/epidemiología , Infecciones Comunitarias Adquiridas/epidemiología , Intervalos de Confianza , Femenino , Humanos , Medicina Interna/estadística & datos numéricos , Masculino , Análisis Multivariante , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROCRESUMEN
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