Longitudinal clinical findings and outcome among patients with Cryptococcus gattii infection in British Columbia.

BACKGROUND: Cryptococcus gattii (Cg) infection emerged in British Columbia in 1999. A longitudinal, clinical description of patients has not been reported. METHODS: Medical records were reviewed for Cg patients identified through surveillance (1999-2007). Risk factors for Cg mortality were explored using multivariate Cox regression; longitudinal patterns in serum cryptococcal antigen (SCrAg) titers and the probability of chest cryptococcomas over time were estimated using cubic B-splines in mixed-effects regression models. RESULTS: Among 152 patients, 111 (73.0%) were culture confirmed. Isolated lung infection was present in 105 (69.1%) patients; 47 (30.9%) had central nervous system infection, with or without lung involvement. Malignancy was the provisional diagnosis in 64 (42.1%) patients. Underlying diseases were present in 91 (59.9%) patients; 23 (15.1%) were immunocompromised, and 23 (15.1%) had asymptomatic disease. There were only 2 (1.8%) culture positive relapses, both within 12 months of follow-up. The estimated median time to resolution of lung cryptococcomas and decline in SCrAg titer to <1:8 was 2.8 and 2.9 years, respectively. Cg-related and all-cause mortality among culture-confirmed cases at 12 months' follow-up was 23.3% and 27.2%, respectively. Cg-related mortality was associated with age >50 years (hazard ratio [HR], 15.6; 95% confidence interval [CI], 1.9-130.5) and immunocompromise (HR, 5.8; CI, 1.5-21.6). All Cg-related mortality occurred among culture-positive cases within 1 year of diagnosis. CONCLUSIONS: Cryptococcomas and serum antigenemia were slow to resolve. However, late onset of failed therapy or relapse was uncommon, suggesting that delayed resolution of these findings does not require prolongation of treatment beyond that recommended by guidelines.

Community-onset bloodstream infection during the 'after hours' is not associated with an increased risk for death.

BACKGROUND/OBJECTIVE: Patients admitted to hospital during the 'after hours' (weekends and evenings) may be at increased risk for adverse outcome. The objective of the present study was to assess whether community-onset bloodstream infections presenting in the after hours are associated with death. METHODS: All patients in the Victoria area of British Columbia, who had first admissions with community-onset bloodstream infections between 1998 and 2005 were included. The day of admission to hospital, the day and time of culture draw, and all-cause, in-hospital mortality were ascertained. RESULTS: A total of 2108 patients were studied. Twenty-six per cent of patients were admitted on a weekend. Blood cultures were drawn on a weekend in 27% of cases and, in 43%, 33%, and 25% of cases, cultures were drawn during the day (08:00 to 17:59), the evening (18:00 to 22:59) and night (23:00 to 07:59), respectively. More than two-thirds (69%) of index cultures were drawn during the after hours (any time Saturday or Sunday and weekdays 18:00 to 07:59). The overall in-hospital case fatality rate was 13%. No difference in mortality was observed in relation to the day of the week of admission or time period of sampling. After-hours sampling was not associated with mortality in a multivariable logistic regression model examining factors associated with death. CONCLUSION: Presentation with community-onset, bloodstream infection during the after hours does not increase the risk of death.

HISTORIQUE ET OBJECTIF: Les patients hospitalisés « après les heures de travail ¼ (soir et fin de semaine) sont peut-être plus vulnérables aux issues indésirables. La présente étude visait à évaluer si les cas de bactériémie d'origine non nosocomiale qui se présentent après les heures de travail s'associent à des décès. MÉTHODOLOGIE: Tous les patients de la région de Victoria, en Colombie-Britannique, qui avaient été hospitalisés pour la première fois en raison d'une bactériémie d'origine non nosocomiale entre 1998 et 2005 ont participé à l'étude. Les chercheurs ont déterminé le jour de l'hospitalisation, le jour et l'heure du prélèvement de culture et la mortalité toutes causes confondues en milieu hospitalier. RÉSULTATS: Au total, 2 108 patients étaient à l'étude. Vingt-six pour cent ont été hospitalisés pendant la fin de semaine. Des cultures sanguines ont été prélevées la fin de semaine dans 27 % des cas, et dans 43 %, 33 % et 25 % des cas, elles l'ont été pendant la journée (entre 8 h et 17 h 59), le soir (18 h à 22 h 59) et la nuit (23 h à 7 h 59), respectivement. Plus des deux tiers (69 %) des cultures de référence avaient été prélevées après les heures de travail (en tout temps le samedi ou le dimanche et la semaine entre 18 h et 7 h 59). Le taux cas-décès global en milieu hospitalier s'élevait à 13 %. Les chercheurs n'ont observé aucune différence de mortalité selon le jour d'hospitalisation ou la période de l'échantillonnage. D'après le modèle de régression logistique multivariable portant sur les facteurs liés aux décès, les cas après les heures de travail ne s'associaient pas à des décès. CONCLUSION: Le fait de se présenter avec une bactériémie d'origine non nosocomiale après les heures de travail n'accroît pas le risque de décès.

Tuberculous epididymitis following intravesical Bacillus Calmette-Guérin immunotherapy.

Intravesical Bacillus Calmette-Guérin (BCG) is widely used as an adjuvant therapy in the treatment of superficial bladder cancer. BCG is administered as a live, attenuated form of Mycobacterium bovis, and acts as an immunomodulary agent to delay tumor progression. BCG is generally well tolerated, though localized and systemic infectious complications may occur. A literature search revealed that tuberculous epididymitis is a rarely reported complication of intravesical BCG therapy. We report the case of an 82-year-old male who developed tuberculous epididymitis while undergoing intravesical BCG treatment for transitional cell carcinoma of the bladder. Right orchiectomy was performed, followed by rifampin and isoniazid therapy once M. bovis was identified as the infectious agent. The patient responded well to these treatments, and made a full recovery. Tuberculous epididymitis is an uncommon complication resulting from intravesical BCG therapy, which is likely explained by retrograde migration from the prostatic urethra in this case.