Severe diphtheria with neurologic and myocardial involvement in a Swedish patient: a case report.

BACKGROUND: Diphtheria is caused by Corynebacterium diphtheriae. Although waning in incidence diphtheria can cause severe disease as in this rare Swedish case with several complications. CASE PRESENTATION: A 55-year old male presented to the emergency room with severe respiratory symptoms and greyish membranes in the airways, which turned positive for C. diphtheriae. He was put on ventilator support and remained hospitalized for three months. During care he developed myocarditis and severe neurological disease and he was also co-infected with tuberculosis. The patient was discharged with a favorable outcome. CONCLUSIONS: Diphtheria should be suspected in patients with life-threatening pneumonia especially if the patient has a history of travelling. Our patient was not treated with diphtheria anti-toxin (DAT) which may have contributed to the severity of the disease.

Detrimental effects of specific Periodontopathic bacterial infection on tachyarrhythmia compared to Bradyarrhythmia.

BACKGROUND: Tachyarrhythmia (TA) and bradyarrhythmia (BA) are cardiac rhythm disorders that result in the decline of quality of life. While patients with periodontitis are at a high risk of cardiovascular disease (CVD), little causal information between TA and BA has been provided to date. To assess the relationship, periodontal bacterial infection in patients with TA or BA was evaluated. METHODS: The subjects were patients with TA (n = 98) or BA (n = 40) who attended Tokyo Medical and Dental University hospital. Periodontal and blood examinations were performed. Periodontopathic bacterial existence in saliva was evaluated. RESULTS: We found that specific periodontopathic bacteria, Porphyromonas gingivalis and Prevotella intermedia, were highly detected in saliva from TA patients compared to BA subjects. The rates of hypertension and dyslipidemia were comparable between the two groups. CONCLUSION: Specific periodontal bacterial infection might affect TA progression.

An unusual case of sepsis: liver abscess masquerading as pneumonia.

A 63-year-old woman presented with fever, tachycardia and tachypnoea, with right sided chest and hypochondrial pain. Chest radiograph showed right basal consolidation and she was treated for community acquired pneumonia with intravenous antibiotics. Subsequent clinical deterioration in presence of a previous history of complicated diverticulitis, persistent right hypochondrial pain and deranged liver function tests prompted further investigations that confirmed presence of a large pyogenic liver abscess. Following appropriate antibiotic treatment and image guided drainage of the abscess, the patient made a complete recovery. This case illustrates the importance of considering a subdiaphragmatic source of sepsis even in the presence of chest radiographic abnormalities, when a patient fails to respond to initial treatment for pneumonia.

Unexplained persistent postpartum palpitations and tachycardia due to Group A Streptococcus.

BACKGROUND: Group A Streptococcus is one of the most morbid infections in modern obstetric practice. Pregnant women are known to have a 20-fold increased risk of invasive Group A Streptococcus with greatest risk in the first 4 days postpartum. The overwhelming majority of these infections will present with fever, uterine tenderness, or vaginal discharge. A much smaller subset may present to the Emergency Room after initial hospital discharge with much less obvious symptoms. In our case, persistent palpitations with unexplained tachycardia led to improper diagnosis in multiple Emergency Rooms. CASE PRESENTATION: A 37 year-old Caucasian female presents with four post-partum days of unexplained sinus tachycardia and absence of fever, uterine tenderness, or vaginal discharge, which elicits an extensive cardiac and pulmonary workup in multiple Emergency Rooms. Consequent late diagnosis of invasive Group A Streptococcus infection lead to significantly increased morbidity including toxic shock syndrome, acute renal failure, total abdominal hysterectomy and bilateral salpingo-oophorectomy, multiple laparotomies, fasciotomy, intubation, continuous renal replacement therapy, and extensive hospital course and recovery. CONCLUSION: Persistent palpitations with unexplained tachycardia in the post-partum patient in the Emergency Room setting is a potential early warning of Group A Streptococcus infection. Even in the absence of reported clinical fever, uterine tenderness, or vaginal discharge, an early speculum and pelvic exam, with or without consultation with the obstetrics service, is prudent due to the potentially high morbidity or even fatality of Group A Streptococcus infection.

Predictive model for bacteremia in adult patients with blood cultures performed at the emergency department: a preliminary report.

BACKGROUND: Useful predictive models for identifying patients at high risk of bacteremia at the emergency department (ED) are lacking. This study attempted to provide useful predictive models for identifying patients at high risk of bacteremia at the ED. METHODS: A prospective cohort study was conducted at the ED of a tertiary care hospital from October 1 to November 30, 2004. Patients aged 15 years or older, who had at least two sets of blood culture, were recruited. Data were analyzed on selected covariates, including demographic characteristics, predisposing conditions, clinical presentations, laboratory tests, and presumptive diagnosis, at the ED. An iterative procedure was used to build up a logistic model, which was then simplified into a coefficient-based scoring system. RESULTS: A total of 558 patients with 84 episodes of true bacteremia were enrolled. Predictors of bacteremia and their assigned scores were as follows: fever greater than or equal to 38.3°C [odds ratio (OR), 2.64], 1 point; tachycardia greater than or equal to 120/min (OR, 2.521), 1 point; lymphopenia less than 0.5×10(3)/µL (OR, 3.356), 2 points; aspartate transaminase greater than 40IU/L (OR, 2.355), 1 point; C-reactive protein greater than 10mg/dL (OR, 2.226), 1 point; procalcitonin greater than 0.5 ng/mL (OR, 3.147), 2 points; and presumptive diagnosis of respiratory tract infection (OR, 0.236), -2 points. The area under the receiver operating characteristic curves of the original logistic model and the simplified scoring model using the aforementioned seven predictors and their assigned scores were 0.854 (95% confidence interval, 0.806-0.902) and 0.845 (95% confidence interval, 0.798-0.894), respectively. CONCLUSION: This simplified scoring system could rapidly identify high-risk patients of bacteremia at the ED.

Which symptoms and clinical features correctly identify serious respiratory infection in children attending a paediatric assessment unit?

OBJECTIVE: Parent-reported symptoms are frequently used to triage children, but little is known about which symptoms identify children with serious respiratory infections. The authors aimed to identify symptoms and triage findings predictive of serious respiratory infection, and to quantify agreement between parent and nurse assessment. DESIGN: Prospective diagnostic cohort study. SETTING: Paediatric Assessment Unit, University Hospitals Coventry and Warwickshire NHS Trust. PATIENTS: 535 children aged between 3 months and 12 years with suspected acute infection. METHODS: Parents completed a symptom questionnaire on arrival. Children were triaged by a nurse, who measured routine vital signs. The final diagnosis at discharge was used as the outcome. Symptoms and triage findings were analysed to identify features diagnostic of serious respiratory infection. Agreement between parent and triage nurse assessment was measured and kappa values calculated. RESULTS: Parent-reported symptoms were poor indicators of serious respiratory infection (positive likelihood ratio (LR+) 0.56-1.93) and agreed poorly with nurse assessment (kappa 0.22-0.56). The best predictor was clinical assessment of respiratory distress (LR+ 5.04). Oxygen saturations <94% were highly specific (specificity 95.1%) but had poor sensitivity (35.6%). Tachypnoea (defined by current Advanced Paediatric Life Support standards) offered little discriminatory value. CONCLUSION: Parent-reported symptoms were unreliable discriminators of serious respiratory infection in children with suspected acute infection, and did not correlate well with nurse assessment. Using symptoms to identify higher risk children in this setting is unreliable. Nurse triage assessment of respiratory distress and some vital signs are important predictors.

[Determinants of group B streptococcus maternal colonization and factors related to its vertical perinatal transmission: case-control study]. / Déterminants de la colonisation maternelle à streptocoque B et facteurs associés à sa transmission verticale périnatale: étude cas-témoins.

OBJECTIVES: To investigate the determinants of Group B streptococcus (GBS) maternal colonization, as well as factors associated with its vertical transmission. PATIENTS AND METHODS: Case-control study on all singletons pregnancies delivered beyond at least 24 weeks of amenorrhoea in Southern Reunion maternities for which GBS screening was known. Multiple logistic regression analysis using 2004-2007 dataset of South Reunion birth registers. RESULTS: Out of 17,430 women delivered between 1st January 2004 and 31st December 2007, 2911 (16.7%) carried GBS. In a model adjusted on antenatal care, risk groups for GBS carriage were the women indigenous from another island of the Indian Ocean than Reunion (OR: 1.29, CI95%: 1.05-1.57) and obese women (body mass index ≥ 30, OR: 1.19, CI95%: 1.03-1.18). Protective factors included birthplace in mainland France (OR: 0.82, CI95%: 0.69-0.97) and underweight (OR: 0.81; CI95%: 0.69-0. 95). In a model controlling for a composite obstetrical variable delineating the protective roles of C-section and antibioprophylaxis as well as the putative role of meconium-stained fluids (thin, thick or fetid), all previously found in our setting, three key factors were independently associated with GBS vertical mother-to-child transmission: obesity (OR: 1.48, CI95%: 1.05-2.09), fetal tachycardia (OR: 4.92, CI95%: 2.79-8.68) and late preterm birth (35 to 36 wks, OR: 2.14, CI95%: 1.32-3.45). CONCLUSION: These findings strengthen the putative roles of corpulence and ethnicity in GBS acquisition previously found in the United States, while confirming an authentic role of obesity in its vertical transmission, independently of other classical cofactors lighted by our study.

Evaluation of temperature-pulse centile charts in identifying serious bacterial illness: observational cohort study.

BACKGROUND: Distinguishing serious bacterial infection (SBI) from milder/self-limiting infections is often difficult. Interpretation of vital signs is confounded by the effect of temperature on pulse and respiratory rate. Temperature-pulse centile charts have been proposed to improve the predictive value of pulse rate in the clinical assessment of children with suspected SBI. OBJECTIVES: To assess the utility of proposed temperature-pulse centile charts in the clinical assessment of children with suspected SBI. STUDY DESIGN AND PARTICIPANTS: The predictive value for SBI of temperature-pulse centile categories, pulse centile categories and Advanced Paediatric Life Support (APLS) defined tachycardia were compared among 1360 children aged 3 months to 10 years presenting with suspected infection to a hospital emergency department (ED) in England; and among 325 children who presented to hospitals in the UK with meningococcal disease. MAIN OUTCOME MEASURE: SBI. RESULTS: Among children presenting to the ED, 55 (4.0%) had SBI. Pulse centile category, but not temperature-pulse centile category, was strongly associated with risk of SBI (p=0.0005 and 0.288, respectively). APLS defined tachycardia was also strongly associated with SBI (OR 2.90 (95% CI 1.60 to 5.26), p=0.0002). Among children with meningococcal disease, higher pulse and temperature-pulse centile categories were both associated with more severe disease (p=0.004 and 0.041, respectively). CONCLUSIONS: Increased pulse rate is an important predictor of SBI, supporting National Institute for Health and Clinical Excellence recommendations that pulse rate be routinely measured in the assessment of febrile children. Temperature-pulse centile charts performed more poorly than pulse alone in this study. Further studies are required to evaluate their utility in monitoring the clinical progress of sick children over time.

Triggering receptor (TREM-1) expressed on myeloid cells predicts bacteremia better than clinical variables in community-acquired pneumonia.

BACKGROUND AND OBJECTIVE: Some clinical variables are associated with bacteremia in patients with community-acquired pneumonia (CAP). The aim of this study was to analyse the accuracy of the soluble form of triggering receptor expressed on myeloid cells-1 (sTREM-1) to predict positive blood cultures in comparison with established clinical prognostic variables. METHODS: In addition to collecting clinical and laboratory information, a commercially available immunoassay kit was used to measure the serum sTREM-1 levels on the first day of admit ion in patients with CAP. Receiver operating characteristic (ROC) curves were used to compare the ability of sTREM-1 and commonly used clinical variables to identify bacteremia. RESULTS: Blood cultures yielded a pathogen in 13 (10.4%) out of 124 patient samples. The microorganisms isolated were Streptococcus pneumoniae (11 patients) and Klebsiella pneumoniae (2 patients). The presence of pleuritic chest pain, tachycardia and extreme white cell count (WCC) were associated with bacteremia. However, ROC curve analysis showed an accuracy of sTREM-1 (area under the receiver operating characteristic curve (AUC) 0.84, 95% CI: 0.72-0.95), which was higher than pleuritic chest pain (AUC 0.71, 95% CI: 0.57-0.84), tachycardia (AUC 0.73, 95% CI: 0.58-0.88) and extreme WCC (AUC 0.70, 95% CI: 0.55-0.85) for predicting positive blood cultures. Low admission sTREM-1 serum values had a high negative predictive value for excluding bacteremia (sTREM-1 <120 pg/mL = 98.8%). CONCLUSIONS: This preliminary study suggests that the determination of sTREM-1 serum levels on admission may be more accurate than clinical variables for identifying bacteremic patients.

Transient dysautonomia and cerebellitis in childhood enteric fever.

A case of childhood enteric fever complicated by transient dysautonomia and cerebellitis is reported. The child was treated with intravenous antibiotics, and the complications were managed conservatively. Dysautonomia and cerebellitis resolved by day 5 and day 8 after admission, respectively. Results of a neurologic examination at the end of 6 months were normal. Dysautonomia complicating the course of childhood enteric fever is previously unreported.

[Clinical case of the month. Fatal pertussis infection in a 2 month old infant]. / Le cas clinique du mois. Coqueluche fatale chez un nourrisson de deux mois.

The incidence of B pertussis has increased by 50% from the 1980s to the 1990s, primarily among those aged 4 months and younger. Worldwide, pertussis is a significant cause of infectious mortality with 40 million cases and 400.000 deaths. Most of these cases and deaths occur in infancy. Symptoms vary from common cold in adults to respiratory distress in infants. Non immune babies with respiratory disease and significant lymphocytosis should be considered to have pertussis until proven otherwise. The onset of severe pulmonary hypertension during B pertussis pneumonia is frequenly rapid and relentless. Exchange-transfusion can be life-saving by reducing the leucocyte mass. Classic vaccination or boosters given to adults and adolescents would reduce the spread from parents tho infants, but a new vaccination schedule is under investigation at Vanderbilt Children's Hospital to give baby's first pertussis vaccination at birth?

[Cardiac manifestations of Lyme borreliosis]. / Objawy kardiologiczne w przebiegu boreliozy z Lyme.

Lyme borreliosis is increasing in Poland in both incidence and recognition with 655 cases reported in 1997 and 3574 in 2003. Approximately 4% of patients will develop cardiac manifestations--the least well documented complication of Lyme disease. Cardiac involvement usually occurs within weeks to months of the infecting tick bite and includes varying degrees of atrioventricular block as the commonest manifestation and tachyarrhythmias, myopericarditis, mild cardiac muscle dysfunction. There has been evidence that long standing dilated cardiomyopathy may be associated with chronic Borrelia burgdorferi infection. Patients with atrioventricular block have good prognosis. Most cases resolve within 1 to 2 weeks. Temporary, but almost never permanent, cardiac pacing may be required for some patients. Cardiac manifestations of Lyme disease are treatable with antibiotics. Lyme carditis should be taken into consideration in patients with acute as well as chronic heart diseases.

Associations between physical examination, laboratory, and radiographic findings and outcome and subsequent racing performance of foals with Rhodococcus equi infection: 115 cases (1984-1992).

OBJECTIVE: To determine whether physical examination, laboratory, or radiographic abnormalities in foals with Rhodococcus equi infection were associated with survival, ability to race at least once after recovery, or, for foals that survived and went on to race, subsequent racing performance. DESIGN: Retrospective study. ANIMALS: 49 Thoroughbreds and 66 Standardbreds admitted to 1 of 6 veterinary teaching hospitals between 1984 and 1992 in which R equi infection was positively diagnosed. PROCEDURE: Results of physical examination, laboratory testing, and thoracic radiography were reviewed. Indices of racing performance were obtained for foals that recovered and eventually raced and compared with values for the US racing population. RESULTS: 83 (72%) foals survived. Foals that did not survive were more likely to have extreme tachycardia (heart rate > 100 beats/min), be in respiratory distress, and have severe radiographic abnormalities on thoracic radiographs at the time of initial examination than were foals that survived. Clinicopathologic abnormalities were not associated with whether foals did or did not survive. Forty-five of the 83 surviving foals (54%) eventually raced at least once, but none of the factors examined was associated with whether foals went on to race. Racing performance of foals that raced as adults was not significantly different from that of the US racing population. CLINICAL IMPLICATIONS: R equi infection in foals is associated with a decreased chance of racing as an adult; however, foals that eventually go on to race perform comparably to the US racing population.