First case of COVID-19 complicated with fulminant myocarditis: a case report and insights.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has been demonstrated to be the cause of pneumonia. Nevertheless, it has not been reported as the cause of acute myocarditis or fulminant myocarditis. CASE PRESENTATION: A 63-year-old male was admitted with pneumonia and cardiac symptoms. He was genetically confirmed as having COVID-19 according to sputum testing on the day of admission. He also had elevated troponin I (Trop I) level (up to 11.37 g/L) and diffuse myocardial dyskinesia along with a decreased left ventricular ejection fraction (LVEF) on echocardiography. The highest level of interleukin-6 was 272.40 pg/ml. Bedside chest radiographs showed typical ground-glass changes indicative of viral pneumonia. Laboratory test results for viruses that cause myocarditis were all negative. The patient conformed to the diagnostic criteria of the Chinese expert consensus statement for fulminant myocarditis. After receiving antiviral therapy and mechanical life support, Trop I was reduced to 0.10 g/L, and interleukin-6 was reduced to 7.63 pg/mL. Moreover, the LVEF of the patient gradually recovered to 68%. The patient died of aggravation of secondary infection on the 33rd day of hospitalization. CONCLUSION: COVID-19 patients may develop severe cardiac complications such as myocarditis and heart failure. This is the first report of COVID-19 complicated with fulminant myocarditis. The mechanism of cardiac pathology caused by COVID-19 needs further study.

Post-Thoracic Endovascular Aortic Repair Complicated with Mycotic Aneurysm Rupture, Repaired by Redo Thoracic Endovascular Aortic Repair.

Mycotic aneurysms although rare can be devastating. We encountered a dialysis patient with rapidly expanding distal aortic arch aneurysm who underwent axilloaxillary bypass and thoracic endovascular aortic repair (TEVAR). Three months later, he suffered mycotic aneurysm rupture for which redo TEVAR was performed. Antibiotic therapy was discontinued 16 weeks after the second operation, and renal transplantation was performed 6 months later. Dialysis was discontinued in the patient without infection recurrence.

Infection with bacteroides thetaiotaomicron during posterior decompression and dynamic stabilization of the lumbar spine: a case report and review of the literature.

Patient and surgical risk factors have often been implicated for postoperative posterior spinal wound infection. A 56-year-old male with widely disseminated multiple myeloma presented with severe back pain and lower extremity weakness as a result of fracture and collapse of the L4 vertebral body. Posterior decompression involving bilateral pedicle resection and partial L4 corpectomy was performed. Stabilization was performed by Dynesys instrumentation of L3-5, screw supplementation with polymethylmethacrylate, and posterolateral fusion was performed. Postoperatively, the patient suffered from multiple infections, including Bacteroides thetaiotaomicron, which were eventually resolved with antibiotic as well as incision and debridement treatment regimens. In cases with numerous perioperative risk factors for infections, the best therapeutic approach may be a preventative one. An understanding of the relevant risk factors may enable the physician to facilitate a perioperative condition best suited for optimal treatment. A case report of infection with Bacteroides thetaiotaomicron during lumbar decompression and dynamic stabilization as well as a review of the literature regarding infection risk factors are presented.

Spleen rupture associated with septic emboli and endocarditis in a hemodialysis patient.

We present an uremic patient on chronic hemodialysis with splenic septic emboli associated with active infective endocarditis and anaerobic bacteremia complicated by ruptured spleen. A 62-year-old female patient was admitted because of fever and pain in the left upper abdomen and swelling and hematoma around the left brachiocephalic arteriovenous fistula. Transthoracic echocardiography revealed mobile hyperechoic mass (vegetation) on the anterior mitral valve. Abdominal ultrasound scan showed multiple hypoechoic lesions of the enlarged spleen, described as possible necroses or abscesses, and computed tomography showed low-density inhomogeneous lesions in the enlarged spleen with large perisplenic hematoma, with spleen rupture. Blood culture revealed anaerobic Gram-negative bacilli ( Bacteroides spp.), ampicillin resistant. This is the first report of splenic rupture associated with anaerobic bacteremia and splenic septic emboli in a uremic patient on chronic hemodialysis. Splenic septic emboli with abscess/infarction in hemodialysis patients are a rare disorder but could be a consequence of dialysis access site infection and might predispose to splenic rupture. Ultrasound scan of abdomen is fast, inexpensive and easy to perform. As mortality is high, early surgical intervention on vascular access is mandatory.

Spontaneous Bacteroides fragilis spondylodiscitis in an elderly lady.

A 76-year-old woman presented following two episodes of unexplained falls at home. Blood cultures were positive for Bacteroides fragilis and following investigations she was diagnosed with L4/L5 spondylodiscitis confirmed on spine MRI. She was initially treated with intravenous metronidazole and flucloxacillin prior to switching to ceftriaxone with good results. No primary cause of B. fragilis bacteraemia was found in this case. B. fragilis is a rare cause of spondylodiscitis.

Diffusion-weighted imaging is helpful in the accurate non-invasive diagnosis of breast abscess: correlation with necrotic breast cancer.

Clinical differentiation of atypical breast abscesses from necrotic tumour in premenopausal women is challenging and may delay appropriate therapy. In this case report, we present a 36-year-old woman with signs, symptoms and conventional imaging features of malignancy who underwent breast MRI. On diffusion-weighted imaging (DWI), profoundly low apparent diffusion coefficient values were a distinguishing sign of breast abscess from necrotic breast cancer, and helped manage the patient conservatively. We present a companion case of necrotic breast tumour highlighting significant differences in DWI.

Lemierre Syndrome associated with dental infections. Report of one case and review of the literature.

The first publication on Lemierre Syndrome appears in 1936 by Lemierre. It is defined as an "oropharynx bacterial infection characterized by the thrombophlebitis in the internal jugular vein, derived in a systemic septic embolism". In 81% of the cases, the Fusobacterium necrophorum is the most frequent etiologic agent. Fever is the most common symptom, but it can depending on the primary infection, tonsillitis, mastoiditis or odontogenic infection. According to the literature the mortality is very low, but with a significant morbidity, that is why the diagnosis and early treatment is very important. The diagnosis it's clinical, even though the CT scan and other diagnosis methods (echography, MRI) help to determine the extent of the infection. It's necessary to administer the antibiotics endovenous at high dose, (keeping in mind that the most frequent micro organism is anaerobic), and vital support measures if necessary. We present a case report of Lemierre Syndrome associated to an odonthogenic infection caused by the 4.8 molar.

[The Vulnerable Heel of Achilles: Intratendinous Abscess Following a Cat Bite]. / Die vulnerable Ferse des Achilles ­ intratendinöser Abszess nach Katzenbiss.

An 83-year-old patient suffered a cat bite dorsally to the Achilles tendon. In the further course, he developed an isolated intratendinous abscess of the Achilles tendon, which was surgically revised twice and subsequently healed with antibiotic treatment. In Germany, about 40,000 bite injuries of different origins occur annually. Most of these injuries are cat or dog bites, while human bites are rare. Although the course is often complicated, there are no standard recommendations for treatment. An intratendinous abscess after animal bite injury has not been described in the literature as yet.

Pylephlebitis associated with acute infected choledocholithiasis.

Pylephlebitis, also called septic thrombophlebitis of the portal vein, is a life-threatening complication of intra-abdominal infection. Although rare, it remains a less recognized entity with a high rate of mortality. We present a 66-year-old man with acute infected choledocholithiasis complicated with Bacteroides fragilis bacteremia. The contrast-enhanced computed tomography scan of the abdomen showed nearly total thrombotic occlusion of the left portal vein. The comprehensive studies for hypercoagulation disorders all yielded negative results. After endoscopic extraction of bile duct stones and broad-spectrum antibiotic therapy, the patient recuperated with complete recanalization of the occluded portal vein. To our knowledge, pylephlebitis associated with acute infected choledocholithiasis has never been reported. This report details the clinical features, radiographic findings, pathogenesis, and treatment of this distinctly unusual manifestation. Early identification of pylephlebitis and underlying intra-abdominal infection can be achieved by exquisite imaging studies with raised awareness in the clinical setting. Eradication of infectious foci and judicious administration of antimicrobials are essential to reduce the catastrophic morbidity and mortality of pylephlebitis.

The rim sign in hepatic abscess: case report and review of the literature.

UNLABELLED: We studied a previously healthy patient who presented with a 3-wk history of fever, flu-like symptoms and abdominal pain. METHODS: Blood cultures were positive for Escherichia coli. A computed tomography (CT) scan revealed a 2-cm low-density focus in the right hepatic lobe. A technetium-99m-mebrofenin scan showed a photopenic area in the right hepatic lobe surrounded by a rim of activity greater than the adjacent parenchymal activity. RESULTS: Gallbladder visualization was normal and the diagnosis of hepatic abscess was made. CT-guided percutaneous drainage of the lesion yielded six cc of pus, the culture of which grew E. coli, Prevotella and Bacteroides fragilis. Drainage and a 6-wk course of intravenous antibiotics were followed by clinical improvement and resolution of the abscess by CT. CONCLUSION: The rim sign and its possible mechanism of causation in hepatic abscess are discussed in this report, together with a review of the literature.

Computed tomographic evaluation of an experimental model for pyogenic liver abscesses.

Computed tomography (CT) was used to evaluate 15 rabbits with experimentally induced liver abscesses. The animals were examined both before and after intravenous contrast injection. After sacrificing the animals, postfreeze CT scans were made to mark the abdomen for 1-cm thick whole body sections for correlating the gross pathology with the results of the CT scans. CT detected 15 abscesses in 13 of the 14 rabbits with true positive lesions. Ten abscesses less than 1.4 cm in diameter were not detected by CT. Contrast agent enhancement was helpful in 70% of the studies. These abscesses have characteristics similar to human liver abscesses, but there was more gas and calcium in the experimentally induced abscesses than is encountered in humans with hepatic abscesses. The model and its CT characteristics appear well suited for future studies in the diagnosis and treatment of liver abscesses.

Endoscopic stereotactic treatment of brain abscesses.

Treatment of brain abscess is still a subject of controversy. Craniotomy with primary extirpation and resection of the abscess membrane, burrhole craniotomy with puncture or insertion of a drain, marsupialization, or stereotactic aspiration are different therapeutic approaches. As a consequence of our experiences and results with neuro-endoscopic interventions we have introduced endoscopic stereotactic techniques in brain abscess treatment. Seven patients with brain abscesses were operated on stereotactically using an endoscope. In all cases the abscess contents were aspirated, while the abscess membrane was left in situ. The patients received postoperative antibiotic therapy according to microbial diagnosis. The longest follow-up period was 48 months. Six patients showed a marked improvement of neurological deficit after treatment. One patient died from sepsis caused by a bacterial endocarditis. The results emphasize that endoscopic stereotactic technique as a minimally invasive neurosurgical method can also be used for treatment of brain abscess.

Anaerobic osteomyelitis--treatment with metronidazole in an experimental rabbit model.

Anaerobic micro-organisms are important agents in chronic bone infections. Their pathogenic role, however, is still unclear partly because of methodological reasons. In this paper an experimental model of osteomyelitis is used for studies of metronidazole treatment of bone infections induced by Bacteroides fragilis. The proximal tibial metaphyses of ten New Zealand white rabbits were excavated and filled with sheets of polyvinyl alcohol, into which a suspension of B. fragilis cells was injected on the right side, while saline was used on the left side. Within a month the animals showed immunological and radiological signs of an established bone infection. After 25 weeks of observation, four animals were treated with subcutaneous injections of metronidazole at a dosage of 10 mg/kg body weight twice daily for three weeks and five animals received saline. After 37 weeks the animals were killed. Radiological, histological and microbiological evaluation showed bilateral osteomyelitis in all animals. Prolonged raised titres of antibodies suggested an established infection, and not merely a colonization. There were no differences between the animals treated with metronidazole and the animals not treated.

A swollen cheek, an unusual course of acute mastoiditis.

An acute mastoiditis can occasionally present as a swelling in front of the ear. An inflammation of the air cells of the mastoid cavity can spread, via the cells in the root of the zygomatic arch, to the soft tissues of the cheek. Unfamiliarity with this underlying cause of a swollen cheek can lead to delay of proper treatment with potential harm to the patient. This case presents such an uncommon form of mastoiditis in a 3-year-old boy; the failure to recognize the disease initially led to extensive osteomyelitis of the temporal bone. CT scanning was important in establishing the cause of the persistently severe condition of the boy, in spite of bilateral myringotomies and mastoidectomy on the right side. Destruction of bone from the zygomatic arch to the suture between temporal and occipital bone was shown. Extensive removal of diseased bone was achieved neurosurgically, thus leading to uneventful recovery.

Intra-abdominal abscess demonstrating an unusually large intra-abdominal pattern on an indium-111 leukocyte scan.

Indium-111 WBC imaging of a patient with occult septicemia revealed a large focal pattern of radiopharmaceutical distribution within the abdominal cavity at 24 hours post radiopharmaceutical administration. This finding was felt to represent a large intra-abdominal abscess. A five liter peritoneal abscess was found at surgery. This case illustrates an unusual presentation of an intra-abdominal abscess.

Unexpected reversal of gallium-67 citrate avidity in an anaerobic hepatic abscess.

A case of anaerobic hepatic abscess (Bacteroides fragilis), which initially was imaged as a cold defect on Ga-67 citrate scintigraphy and, following percutaneous drainage, became Ga avid, is presented. Proposed mechanisms for this occurrence are given.

Primary psoas abscess. Report of three cases.

BACKGROUND: Primary psoas abscesses are a rare clinical entity with subtle and non specific symptoms, most commonly seen in patients predisposed to infections. Early diagnosis and appropriate management are therefore challenging aspects for physicians. PATIENTS AND METHODS: We present three patients with primary pyogenic psoas abscess, treated at the Heraklion University Hospital, during a 5-year period. The two male and one female patient, aged 36-51 years were admitted with fever, abdominal pain and a palpable tender mass. RESULTS: The classical sign of limping was absent in all cases. Positive psoas symptoms were detected in only two patients. CT scan accurately confirmed the diagnosis in all cases. The patients were successfully treated with antibiotics and prolonged surgical drainage. Staphylococcus aureus was the causative microorganism in the first two and Bacteroides fragilis in the third patient. This is the first reported case resulting from this specific bacteria. None of our patients had any predisposing risk factor. CONCLUSIONS: A high index of suspicion is mandatory to enable early recognition of this rare clinical disease. CT scan is the standard diagnostic tool to confirm diagnosis. Prolonged drainage and appropriate antibiotics are essential for the successful treatment of primary psoas abscesses.

[Primary abscess of the psoas]. / Abscesos primarios de psoas.

We present in this paper a series of cases from our Service of primary abscesses in psoas. We consider the appearance of immunosuppressed patients as a relevant factor of its etiopathogenicity. We believe that a C.A.T. is the best diagnostic method. All three patients that underwent open surgery have had complications. The patients treated with percutaneous puncture has shown a favourable evolution.