Austrian Syndrome: Community-Acquired Pneumonia in an Unusual Triad.

Austrian syndrome corresponds to the triad of meningitis, pneumonia, and endocarditis caused by Streptococcus pneumoniae, there is no global or local incidence given the infrequency of entity. Scarce cases are published in Latin America, with none of them in Colombia. A case of Austrian syndrome by penicillin-resistant S. pneumoniae in an immunocompetent patient is presented. Aortic valve is the most frequent site involved in Austrian syndrome; this patient had an unusual localization of the vegetation on the right coronary artery ostium. The prognosis is poor with a mortality rate of 30% or higher, this patient survived despite systemic complications. Vaccination status impacts in prevention and severity of cases because responsible serotypes are often included in available vaccines. The patient had a serotype covered by available vaccines; however, her vaccination status was unknown. Thus, we present the first case reported in Colombia of Austrian syndrome by a penicillin-resistant S. pneumoniae, in a patient with no identified comorbidities or toxicological history, with a successful evolution.

Indole alkaloids inhibit zika and chikungunya virus infection in different cell lines.

BACKGROUND: In recent years, an increase in the occurrence of illnesses caused by two clinically- important arboviruses has been reported: Zika virus (ZIKV) and Chikungunya virus (CHIKV). There is no licensed antiviral treatment for either of the two abovementioned viruses. Bearing in mind that the antiviral effect of indole alkaloids has been reported for other arboviral models, the present study proposed to evaluate the antiviral in vitro and in silico effects of four indole alkaloids on infections by these two viruses in different cell lines. METHODS: The antiviral effects of voacangine (VOAC), voacangine-7-hydroxyindolenine (VOAC-OH), rupicoline and 3-oxo voacangine (OXO-VOAC) were evaluated in Vero, U937 and A549 cells using different experimental strategies (Pre, Trans, Post and combined treatment). Viral infection was quantified by different methodologies, including infectious viral particles by plating, viral genome by RT-qPCR, and viral protein by cell ELISA. Moreover, molecular docking was used to evaluate the possible interactions between structural and nonstructural viral proteins and the compounds. The results obtained from the antiviral strategies for each experimental condition were compared in all cases with the untreated controls. Statistically significant differences were identified using a parametric Student's t-test. In all cases, p values below 0.05 (p < 0.05) were considered statistically significant. RESULTS: In the pre-treatment strategy in Vero cells, VOAC and VOAC-OH inhibited both viral models and OXO-VOAC inhibited only ZIKV; in U937 cells infected with CHIKV/Col, only VOAC-OH inhibited infection, but none of the compounds had activity in A549 cells; in U937 cells and A549 cells infected with ZIKV/Col, the three compounds that were effective in Vero cells also had antiviral activity. In the trans-treatment strategy, only VOAC-OH was virucidal against ZIKV/Col. In the post-treatment strategy, only rupicoline was effective in the CHIKV/Col model in Vero and A549 cells, whereas VOAC and VOAC-OH inhibited ZIKV infection in all three cell lines. In the combined strategy, VOAC, VOAC-OH and rupicoline inhibited CHIKV/Col and ZIKV/Col, but only rupicoline improved the antiviral effect of ZIKV/Col-infected cultures with respect to the individual strategies. Molecular docking showed that all the compounds had favorable binding energies with the structural proteins E2 and NSP2 (CHIKV) and E and NS5 (ZIKV). CONCLUSIONS: The present study demonstrates that indole alkaloids are promising antiviral drugs in the process of ZIKV and CHIKV infection; however, the mechanisms of action evaluated in this study would indicate that the effect is different in each viral model and, in turn, dependent on the cell line.

The Antiviral and Virucidal Activities of Voacangine and Structural Analogs Extracted from Tabernaemontana cymosa Depend on the Dengue Virus Strain.

Currently, no specific licensed antiviral exists for treating the illness caused by dengue virus (DENV). Therefore, the search for compounds of natural origin with antiviral activity is an important area of research. In the present study, three compounds were isolated and identified from seeds of Tabernaemontana cymosa plants. The in vitro antiviral effect of those compounds and voacangine against different DENV strains was assessed using different experimental approaches: compounds added before the infection (Pre), at the same time with the virus (Trans), after the infection (Post) or compounds present in all moments of the experiment (Pre-Trans-Post, Combined treatment). In silico studies (docking and molecular dynamics) were also performed to explain the possible antiviral mechanisms. The identified compounds were three structural analogs of voacangine (voacangine-7-hydroxyindolenine, rupicoline and 3-oxo-voacangine). In the Pre-treatment, only voacangine-7-hydroxyindolenine and rupicoline inhibited the infection caused by the DENV-2/NG strain (16.4% and 29.6% infection, respectively). In the Trans-treatment approach, voacangine, voacangine-7-hydroxyindolenine and rupicoline inhibited the infection in both DENV-2/NG (11.2%, 80.4% and 75.7% infection, respectively) and DENV-2/16681 infection models (73.7%, 74.0% and 75.3% infection, respectively). The latter strain was also inhibited by 3-oxo-voacangine (82.8% infection). Moreover, voacangine (most effective virucidal agent) was also effective against one strain of DENV-1 (DENV-1/WestPac/74) and against the third strain of DENV-2 (DENV-2/S16803) (48.5% and 32.4% infection, respectively). Conversely, no inhibition was observed in the post-treatment approach. The last approach (combined) showed that voacangine, voacangine-7-hydroxyindolenine and rupicoline inhibited over 90% of infections (3.5%, 6.9% and 3.5% infection, respectively) of both strains (DENV-2/NG and DENV-2/16681). The free energy of binding obtained with an in silico approach was favorable for the E protein and compounds, which ranged between -5.1 and -6.3 kcal/mol. Finally, the complex formed between DENV-2 E protein and the best virucidal compound was stable for 50 ns. Our results show that the antiviral effect of indole alkaloids derived from T. cymose depends on the serotype and the virus strain.

Factores relacionados con letalidad en pacientes con bacteriemia hospitalizados por patología médica en una institución de tercer nivel en Colombia, 2014-2016 / Case fatality rate-related factors in patients with bacteremia hospitalized due medical conditions in an institution of third level in Colombia, 2014-2016

Resumen Introducción: Las infecciones del torrente sanguíneo son un problema creciente y actualmente son una amenaza para la salud pública. La bacteriemia representa aproximadamente 15% de todas las infecciones nosocomiales y afecta a 1% de los pacientes hospitalizados. Objetivo: Describir las características clínicas, epidemiológicas y microbiológicas de episodios de bacteriemia nosocomial ocurridos en un hospital colombiano. Pacientes y Métodos: Estudio retrospectivo, observacional, de corte transversal, con inclusión de pacientes adultos, hospitalizados por el Servicio de Medicina Interna en el Hospital Universitario de Santander, Bucaramanga, Colombia, durante los años 2014 a 2016. El protocolo fue aprobado por el Comité de Ética en Investigación de la Universidad Industrial de Santander. Resultados: Se revisaron 450 historias clínicas, con 148 pacientes y 182 aislados microbianos. Los antecedentes más frecuentes fueron: hipertensión arterial (46,6%) e infección por VIH (29,7%). El sistema vascular y urinario ocuparon los sitios anatómicos más frecuentes (37,3 y 38,3%, respectivamente). La letalidad fue de 29%. Los patógenos más frecuentemente aislados fueron: Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli, Pseudomonas aeruginosa (en suma: 49,8%) y Staphylococcus aureus 12,1%. El análisis multivariado mostró relación de la anemia con mortalidad intrahospitalaria (OR = 17,3; IC95% 2,95-102,0). Conclusiones: La bacteriemia es una infección frecuente durante la atención hospitalaria que presenta gran mortalidad. Es destacable el predominio de aislados de enterobacterias multiresistentes. El antecedente de infección por VIH es uno de los más frecuentes el que amerita ser evaluado como grupo de riesgo.

Abstract Background: Bloodstream infections are an increasing problem and currently represent a threat to public health, overcoming diseases such as HIV. Bacteremia accounts for approximately 15% of all nosocomial infections and affects 1% of all hospitalized patients. Aim: To describe the clinical, epidemiological and microbiological characteristic of episodes of nosocomial bacteremia occurring in a Colombian hospital. Methods: Retrospective, observational, cross-sectional study including adult patients, hospitalized in the internal medicine unit at the University Hospital of Santander, Bucaramanga, Colombia, during years 2014 to 2016, who met the criteria of the CDC for bloodstream infection. The protocol was approved by the Hospital Ethics Committee and by the Research Ethics Committee of the Industrial University of Santander. Results: We reviewed 450 clinical records with 148 patients and 182 microbiological isolates. 53% were male. The most frequent comorbidities were: high blood pressure (46.6%), HIV infection (29.7%). The vascular and urinary systems were the most frequent anatomical sites as the source of the infection (respectively 37.3% and 38.3%). Case fatality rate was 29%. The pathogens most frequently isolated were: Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli, Pseudomonas aeruginosa (globally: 49.8%) and Staphylococcus aureus 12.1%. The multivariate analysis showed a relationship between anemia and in-hospital mortality (OR = 17.3, 95%CI 2.95-102.0). Conclusions: Bacteremia is a frequent infection during hospital care that presents high mortality. It is noteworthy the predominance of Enterobacteriaceae isolates with broad profiles of resistance. The history of HIV infection is one of the most frequent which deserves to be evaluated as a risk group.

[Case fatality rate-related factors in patients with bacteremia hospitalized due medical conditions in an institution of third level in Colombia, 2014-2016]. / Factores relacionados con letalidad en pacientes con bacteriemia hospitalizados por patología médica en una institución de tercer nivel en Colombia, 2014-2016.

BACKGROUND: Bloodstream infections are an increasing problem and currently represent a threat to public health, overcoming diseases such as HIV. Bacteremia accounts for approximately 15% of all nosocomial infections and affects 1% of all hospitalized patients. AIM: To describe the clinical, epidemiological and microbiological characteristic of episodes of nosocomial bacteremia occurring in a Colombian hospital. METHODS: Retrospective, observational, cross-sectional study including adult patients, hospitalized in the internal medicine unit at the University Hospital of Santander, Bucaramanga, Colombia, during years 2014 to 2016, who met the criteria of the CDC for bloodstream infection. The protocol was approved by the Hospital Ethics Committee and by the Research Ethics Committee of the Industrial University of Santander. RESULTS: We reviewed 450 clinical records with 148 patients and 182 microbiological isolates. 53% were male. The most frequent comorbidities were: high blood pressure (46.6%), HIV infection (29.7%). The vascular and urinary systems were the most frequent anatomical sites as the source of the infection (respectively 37.3% and 38.3%). Case fatality rate was 29%. The pathogens most frequently isolated were: Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli, Pseudomonas aeruginosa (globally: 49.8%) and Staphylococcus aureus 12.1%. The multivariate analysis showed a relationship between anemia and in-hospital mortality (OR = 17.3, 95%CI 2.95-102.0). CONCLUSIONS: Bacteremia is a frequent infection during hospital care that presents high mortality. It is noteworthy the predominance of Enterobacteriaceae isolates with broad profiles of resistance. The history of HIV infection is one of the most frequent which deserves to be evaluated as a risk group.

Presentación de bacterias resistentes en hemocultivos en pacientes con patología médica en un hospital de tercer nivel

Introducción. Las bacteriemias afectan a pacientes dentro del ámbito hospitalario y se reportan tasas de mortalidad del 35%. Los microorganismos productores de beta-lactamasas de espectro extendido son cada vez más resistentes a los antibióticos. Materiales y métodos. Estudio observacional descriptivo de corte transversal en pacientes mayores de 14 años con hemocultivos positivos en el Hospital Universitario de Santander, entre 2014 y 2016. Resultados. Se analizaron 148 historia clínicas, la edad promedio fue de 55,5 años, el 51,4% eran mujeres. La proporción de gérmenes resistentes fue del 23,6%, la producción de beta-lactamasas de espectro extendido en E. coli y K. pneumoniae fue del 40%. El 100% de los pacientes con gérmenes resistentes tenía un índice de PITT severo. El S. aureus mostró un 50% de resistencia a la oxacilina. Conclusión. El 23,6% de los pacientes tenía una infección por gérmenes resistentes, los más comunes fueron E. coli y K. pneumoniae, la mortalidad general fue del 30%.

Introduction: Bacteremia affects patients in the hospital, with mortality rates reported in 35%. Microorganisms that produce beta- lactamases of extended spectrum are each time more resistant to antibiotics. Method: Observational and descriptive study in patients older tan 14 years old with positive blood cultures in Hospital Universitario de Santander, between 2014 and 2016. Results: 148 clinic records were analyzed, the mean age was 55.5 years. 51.4% were women. The proportion of resistant germs was of 23.6%, the production of beta-lactamases of extended spectrum in E. coli and K. pneumoniae was 40%. 100% of patients with resistant germs had a rate of severe PITT. S. aureus showed a 50% of resistance to oxacillin. Conclusion: 23.6% of patients had an infection for resistant germs, the most common were E. coli and K. pneumoniae. General mortality was of 30%.

Introdução: as bactérias afetam pacientes do contexto hospitalar e relatam taxas de mortalidade de 35%. Os micro-organismos produtores de beta-lactamasas de espectro estendido são cada vez mais resistentes aos antibióticos. Materiais e métodos: estudo observacional descritivo de corte transversal com pacientes maiores de 14 anos com hemoculturas positivas, no Hospital Universitario de Santander, Colômbia, entre 2014 e 2016. Resultados: foram analisados 148 prontuários; a idade média foi de 55,5 anos; 51,4 % eram mulheres. A proporção de germens resistentes foi de 23,6 %; a produção de beta-lactamasas de espectro estendido em E. coli e K. pneumoniae foi de 40%. 100% dos pacientes com germens resistentes tinham um índice de PITT severo. O S. aureus mostrou 50% de resistência à oxacilina. Conclusão: 23,6% dos pacientes tinham uma infecção por germens resistentes, os mais comuns foram E. coli e K. pneumoniae; a mortalidade geral foi de 30%.

Mioclonías posthipóxicas asociadas a estatus epiléptico superrefractario / Post hypoxic myoclonus associated with super refractory status epilepticus

RESUMEN INTRODUCCIÓN: Las mioclonías posthipóxicas aparecen como consecuencia del daño cerebral secundario a hipoxemia severa, con frecuencia en las primeras 24 horas después de la realización de reanimación cardiopulmonar, y los pacientes permanecen en estado de coma por largo tiempo. En general, su aparición constituye un predictor de mal pronóstico. El objetivo de la presentación de este caso es resaltar la presencia de estado epiléptico superrefractario relacionado con mioclonías posthipóxicas. CASO CLÍNICO: Paciente masculino de 24 años con herida de arma cortopunzante en región precordial y toracoabdominal posterior derecha, que ingresa en estado de coma. Es llevado a cirugía y allí se evidencia hemopericardio y herida cardiaca grado III, que fue corregida, con retorno a circulación espontánea pasados 15 minutos desde el inicio de la reanimación cardio-pulmonar y masaje cardiaco bimanual intraoperatorio. Se realiza resonancia magnética cerebral con gadolinio que muestra extensas zonas de isquemia cortical, de tálamos y leve de tallo cerebral, con electroencefalograma que demuestra actividad epiléptica bajo coma barbitúrico con mioclonías generalizadas. CONCLUSIONES: Al analizarse críticamente la clínica, los hallazgos paraclínicos, el estado de conciencia persistente comatoso y la actividad convulsiva con mioclonías, se confirma el diagnóstico de mioclonías posthipóxicas asociadas a estatus epiléptico superrefractario.

SUMMARY INTRODUCTION: Post hypoxic myoclonus appears as a consequence of brain damage secondary to severe hypoxemia, generally occurring in the first 24 hours after performing cardiopulmonary resuscitation and patients remain in a coma for a long time. In general, the appearance of them is a predictor of poor prognosis. The objective of this case is to highlight the presence of super refractory status epilepticus related to post hypoxic myoclonus. CLINICAL CASE: A 24-year-old male with a punctured short gun wound in the precordial region and right thoracoabdominal posterior, who was admitted in a coma. He underwent surgery where hemopericardium and grade III heart injury were corrected, with return to spontaneous circulation after 15 minutes from the start of cardiopulmonary resuscitation and intraoperative bimanual cardiac massage, magnetic resonance imaging of the brain with gadolinium was performed, showing extensive areas of cortical ischemia, of both thalamus and minor in brainstem, with electroencephalogram showing epileptic activity under barbituric coma with generalized myoclonus. CONCLUSIONS: Clinical analysis, paraclinical findings, persistent comatose state of consciousness and seizure activity with myoclonus confirmed the diagnosis of post-hypoxic myoclonus associated with super refractory status epilepticus.

Presentación de bacterias resistentes en hemocultivos en pacientes con patología médica en un hospital de tercer nivel / Presentation of resistant bacteria in blood cultures in patients with medical pathology in a tertiary hospital / Apresentação de bactérias resistentes em hemoculturas em doentes com patologia médica num hospital terciário

Introducción. Las bacteriemias afectan a pacientes dentro del ámbito hospitalario y se reportan tasas de mortalidad del 35 %. Los microorganismos productores de beta-lactamasas de espectro extendido son cada vez más resistentes a los antibióticos. Materiales y métodos . Estudio observacional descriptivo de corte transversal en pacientes mayores de 14 años con hemocultivos positivos en el Hospital Universitario de Santander, entre 2014 y 2016. Resultados. Se analizaron 148 historia clínicas, la edad promedio fue de 55,5 años, el 51,4 % eran mujeres. La proporción de gérmenes resistentes fue del 23,6 %, la producción de beta-lactamasas de espectro extendido en E. coli y K. pneumoniae fue del 40 %. El 100 % de los pacientes con gérmenes resistentes tenía un índice de PITT severo. El S. aureus mostró un 50 % de resistencia a la oxacilina. Conclusión. El 23,6 % de los pacientes tenía una infección por gérmenes resistentes, los más comunes fueron E. coli y K. pneumoniae, la mortalidad general fue del 30 %.

Introduction. Bacteremias affect patients in the hospital setting and mortality rates of 35% are reported. Microorganisms producing extended-spectrum beta-lactamases are increasingly resistant to antibiotics. Materials and methods . Cross-sectional descriptive observational cross-sectional study in patients older than 14 years with positive blood cultures at the Hospital Universitario de Santander, between 2014 and 2016. Results. We analyzed 148 clinical histories, the average age was 55.5 years, 51.4 % were women. The proportion of resistant germs was 23.6 %, the production of extended-spectrum beta-lactamases in E. coli and K. pneumoniae was 40 %. One hundred percent of patients with resistant germs had a severe PITT index. S. aureus showed 50 % resistance to oxacillin. Conclusion. 23.6 % of patients had infection by resistant germs, the most common were E. coli and K. pneumoniae, overall mortality was 30 %.

Introdução. As bacteriémias afectam os doentes em meio hospitalar, tendo sido registadas taxas de mortalidade de 35%. Os microrganismos que produzem beta-lactamases de espetro alargado são cada vez mais resistentes aos antibióticos. Materiais e métodos . Estudo observacional descritivo transversal em pacientes maiores de 14 anos com hemoculturas positivas no Hospital Universitário de Santander, entre 2014 e 2016. Resultados. Foram analisadas 148 histórias clínicas, a idade média foi de 55,5 anos, 51,4 % eram mulheres. A proporção de germes resistentes foi de 23,6 %, a produção de beta-lactamases de espetro alargado em E. coli e K. pneumoniae foi de 40 %. 100 % dos doentes com germes resistentes apresentavam um índice PITT grave. S. aureus apresentou 50 % de resistência à oxacilina. Conclusão. 23,6 % dos pacientes tiveram uma infeção com germes resistentes, os mais comuns foram E. coli e K. pneumoniae, a mortalidade geral foi de 30 %.

Hemoglobina glicosilada y eventos cardiovasculares en pacientes diabéticos de un hospital universitario / Glycosylated hemoglobin and cardiovascular events in diabetic patients of a university hospital

Resumen Introducción: la prevalencia de comorbilidades cardiovasculares generadas por la diabetes mellitus, se desconoce a nivel global en Colombia y más a nivel local. Objetivo: determinar la prevalencia de los eventos cardiovasculares según los niveles de hemoglobina glicosilada (HbA1c), en el Hospital Universitario de Santander. Material y método: estudio observacional analítico retrospectivo tipo corte transversal con pacientes del servicio de medicina interna del Hospital Universitario de Santander en el año 2013. Resultados: la prevalencia de diabetes fue 31.2% (HbA1c>6.5%), de éstos, 52.2% fueron mujeres y la mayoría (70.45%) recibían tratamiento farmacológico. Aunque el infarto agudo de miocardio (10.9%) fue el evento más frecuente, la frecuencia de los diferentes eventos cardiovasculares como motivo de consulta no se relacionaron con algún nivel de HbA1c. Sin embargo, la HbA1c >9% en pacientes >65 años tuvo tendencia de riesgo de ACV, pero sin significancia estadística. Entre los pacientes con HbA1c >9%, 62.02% recibían <4 dosis/día de medicamentos (p=0.000), con una prevalencia alta de muerte intrahospitalaria (88%) siendo el OR de 2.08 (IC95%: 0.85-5.1; p=0.107). Se encontró en el análisis exploratorio, con algunas variables independientes relevantes cierto comportamiento predictivo de niveles de HbA1c no tan altos <9% (AROC 0.67) y otras, para muerte intrahospitalaria (AROC 0.7). Conclusiones: en la población analizada la prevalencia de los eventos cardiovasculares en la población con HbA1c >6.5% fue 31.06%, la categoría HbA1c >9% se relacionó con mayor muerte intrahospitalaria; la HbA1c <9% se relacionó con mayor dosis de tabletas para tratamiento. (Acta Med Colomb 2018; 43: 74-80).

Abstract Introduction: the prevalence of cardiovascular comorbidities generated by Diabetes Mellitus is unknown globally in Colombia and is further unknown locally. Objective: to determine the prevalence of cardiovascular events according to the levels of glycosylated hemoglobin (HbA1c), at the University Hospital of Santander. Material and Method: a cross-sectional, retrospective analytical observational study with patients from the internal medicine service of the University Hospital of Santander in 2013. Results: the prevalence of diabetes was 3l.2% (HbA1c>6.5%); of these 52.2% were women and the majority (70.45%) received pharmacological treatment. Although acute myocardial infarction (10.9%) was the most frequent event, the frequency of the different cardiovascular events as a reason for consultation was not related to any level of HbA1c. However, HbA1c> 9% in patients> 65 years had a risk of stroke, but without statistical significance. Among patients with HbA1c> 9%, 62.02% received <4 doses / day of medication (p = 0.000), with a high prevalence of in-hospital death (88%) with an OR of 2.08 (95% CI: 0.85-5.1; p = 0.107). It was found in the exploratory analysis with some relevant independent variables certain predictive behavior of HbA1c levels not so high <9% (AROC 0.67) and others, for in-hospital death (AROC 0.7). Conclusions: in the population analyzed, the prevalence of cardiovascular events in the population with HbA1c >6.5% was 3l.06%; the category HbA1c> 9% was associated with greater in-hospital death; HbA1c <9% was associated with a higher dose of tablets for treatment. (Acta Med Colomb 2018; 43: 74-80).

MENINGOCOCCEMIA SIN MENINGITIS EN ADULTO JOVEN INMUNOCOMPETENTE: REPORTE DE CASO / MENINGOCOCCEMIA WITHOUT MENINGITIS IN AN INMUNOCOMPETENT YOUNG ADULT: CASE REPORT

La infección causada por Neisseria meningitidis es la responsable de una gran proporción de cuadros de meningitis y sepsis alrededor del mundo en niños y adultos jóvenes. Las presentaciones clínicas más frecuentes de la enfermedad meningocócica son la meningitis y la meningococcemia, aunque esta última no es la más frecuente. La meningococcemia sin meningitis ocurre en una de cada cinco personas que tuvieron la infección, y reporta tasas de mortalidad del 5 % al 20 %. Se presenta un caso de meningococcemia sin meningitis asociado a coagulación intravascular diseminada con recuperación satisfactoria y sin secuelas, diferente a lo descrito en la literatura.

The infection caused by Neisseria meningitidis is responsible of a big proportion of meningitis cases and sepsis in children and young adults around the world. The most frequent clinical features of meningococcal disease are meningitis and meningococcemia, although the latter is not the most frequent. Meningococcemia without meningitis occurs in 1 of 5 people who had the infection, and it is reported that its mortality rates are between 5 % to 20 %. We present a case of meningococcemia without meningitis associated to intravascular disseminated coagulation with successful recovery and with no sequels, in opposition to what has been described on published researches.