No Impact of Dietary Restrictions on the Risk for Infection in Pediatric Patients With Cancer: A Monocenter Analysis.

PURPOSE: Prophylactic anti-infective strategies are used in patients with cancer to decrease the risk for infection. Dietary restrictions do not allow raw vegetables and fresh fruits to limit the introduction of potentially harmful pathogens in the gastrointestinal tract, but the efficacy is unclear. PATIENTS AND METHODS: In this study analyzing the impact of the dietary restrictions on infectious complications, all children treated between April 2014 and March 2018 for ALL and AML or non-Hodgkin lymphoma (NHL) were included. Dietary restrictions were standard until March 2016, but were stopped in April 2016. Patients with dietary restrictions (treated April 2014-March 2016) and patients not advised for dietary restrictions (treated April 2016-March 2018) were compared regarding infectious complications, including bloodstream infection, pneumonia, diarrhea, and fever of unknown origin (FUO). RESULTS: Eighty-six patients (25 female; 62 ALL; nine AML, 15 NHL) experienced 223 infections. The 46 patients with dietary restrictions and the 40 patients without food restrictions did not significantly differ regarding the number of infections per patient, bloodstream infections, pneumonia, diarrhea, FUO, admission to intensive care, and death. CONCLUSION: Our data suggest that dietary restrictions do not affect the risk for infectious complications. Therefore, the indication of dietary restrictions should be reconsidered in pediatric patients with cancer.

Comparison of two different anti-infectious approaches after high-dose chemotherapy and autologous stem cell transplantation for hematologic malignancies in a 12-year period in British Hospital, Uruguay.

Autologous stem cell transplant (ASCT) is a widely used and safe procedure to treat mostly hematologic diseases. These patients are at risk of infectious complications, which represents a major cause of morbidity and it is the second cause of mortality. This retrospective 12-year analysis of the incidence, type, and severity of infections in 266 consecutive unselected ASCT patients at our institution provides novel information addressing this issue. We included 266 ASCT procedures. Patients included in the 2006-2013 period are referred to as group 1 (ciprofloxacin prophylaxis and ceftazidime-amikacin as empirical antibiotics), and those in the 2013-2017 period are group 2 (levofloxacin prophylaxis and meropenem as empirical antibiotics). The incidence of febrile neutropenia was 72% in group 1 and 86.2% in group 2 (p = 0.004). The majority of infectious episodes were associated with fever of unknown origin: 55% in group 1 and 59% in group 2. Febrile of unknown origin episodes were 82.6% in group 1 and 80% in group 2. Significant differences between both groups were found in age, hypogammaglobulinemia, and advanced disease at ASCT. No differences were found between groups regarding the most common agent documented in positive blood cultures (Gram+ were 66.6% in group 1 and 69% in group 2 (p = 0.68)). Mortality within 100 days of transplant was low, 1.87%. Regardless of the prophylactic regimen used, most patients experience febrile episodes in the ASCT setting, fever of unknown origin is the most common infection complication, and Gram+ agents are prevalent in both groups. Mortality rates were low. According to our results, ASCT is a safe procedure and there is no clear benefit in favor of levofloxacin versus ciprofloxacin prophylaxis. Both anti-infectious approaches are acceptable, yielding similar outcomes.

[Fever and Headache after a Vacation in Thailand]. / Fieber und Kopfschmerzen nach Thailandurlaub.

History 50 year-old man with fever and headache starting one week after returning from his vacation in Thailand. His general practitioner prescribed amoxicillin/clavulanic acid, without further analyses to pinpoint the infection. Examinations The examination of cerebro-spinal fluid was crucial for the final diagnosis. Lumbar puncture demonstrated a predominantly mononuclear pleocytosis of 80 cells/µl (< 5) with an elevated protein of 782 mg/l (< 450); glucose and lactate were within normal limits. Treatment and course Initially we tried to treat a broad range of organisms potentially causing meningitis or encephalitis. Typical bacteria and viruses endemic to Switzerland were not found, thus anti-infective treatment was stopped. Also the search for malaria, HIV, Chikungunya and Dengue infections yielded negative results. After 10 days we received a positive serologic test for Japanese encephalitis virus (JEV). Conclusions The Japanese encephalitis virus is transmitted by mosquitoes and is epidemiologically one of the most important transmissible neurologic diseases in Asia. Although only a minority of infected patients are gravely ill, their sequelae and death toll are considerable. Since 2009 a well-tolerated vaccine is available.

Haemophagocytic syndrome in an adult suffering from pyrexia of unknown origin: an uncommon presentation of tuberculosis: a case report.

BACKGROUND: Tuberculosis is common, can involve various organs of the body and may have diverse presentations. Haemophagocytic syndrome is one of the rare presentations of tuberculosis carrying a very high mortality. Early detection and institution of anti-tuberculosis medications can be life-saving. CASE PRESENTATION: A 23-year-old Bengali man presented with prolonged fever, weight loss, hepatosplenomegaly, pancytopenia and altered liver function. He had high erythrocyte sedimentation rate, positive tuberculin test, granuloma in liver biopsy, and haemophagocytosis was evidenced by histopathological examination of bone marrow. He recovered with anti-tuberculosis therapy. CONCLUSION: This case demonstrates that consideration of tuberculosis as an underlying cause of haemophagocytic syndrome could be rewarding and life-saving in this rapidly fatal condition.

Azithromycin in Labor Lowers Clinical Infections in Mothers and Newborns: A Double-Blind Trial.

BACKGROUND AND OBJECTIVES: We have recently completed a proof-of-concept trial showing that bacterial colonization decreased in women and newborns after the administration of azithromycin during labor. Here, we aim to assess the effect of the intervention on maternal and neonatal clinical infections. METHODS: This was a double-blind, placebo-controlled randomized trial. Gambian women in labor were given either an oral dose of azithromycin (2 g) or placebo. Follow-up was conducted for 8 weeks after delivery. RESULTS: From April 2013 to April 2014, we recruited 829 mothers and their 830 newborns. Sixteen infants died during the follow-up period (8 per arm). No maternal deaths or serious adverse events related to the intervention were reported. Maternal infections were lower in the azithromycin group (3.6% vs 9.2%; relative risk [RR], 0.40; 95% confidence interval [CI], 0.22-0.71; P = .002), as was the prevalence of mastitis (1.4% vs 5.1%; RR, 0.29; 95% CI, 0.12-0.70; P = .005) and fever (1.9% vs 5.8%; RR, 0.33; 95% CI, 0.15-0.74; P = .006). Among newborns, the overall prevalence of infections was also lower in the azithromycin group (18.1% vs 23.8%; RR, 0.76; 95% CI, 0.58-0.99; P = .052) and there was a marked difference in prevalence of skin infections (3.1% vs 6.4%; RR, 0.49; 95% CI, 0.25-0.93; P = .034). CONCLUSIONS: Azithromycin given to women in labor decreases infections in both women and newborns during the puerperal period. Larger studies designed to evaluate the effect of the intervention on severe morbidity and mortality are warranted.

Lack of Effectiveness of Neutropenic Diet and Social Restrictions as Anti-Infective Measures in Children With Acute Myeloid Leukemia: An Analysis of the AML-BFM 2004 Trial.

PURPOSE: Although nonpharmacologic anti-infective measures are widely used in children treated for acute myeloid leukemia (AML), there is little evidence of their effectiveness. PATIENTS AND METHODS: We analyzed infectious complications in children during intensive treatment of AML according to the AML-BFM 2004 trial and surveyed sites on institutional standards regarding recommended restrictions of social contacts (six items), pets (five items), and food (eight items). A scoring system was developed with a restriction score for each item. Multivariable Poisson regression adjusted for sex, age, weight group, risk stratification, and prophylactic antibiotics was used to estimate the impact of the restrictions on the incidence ratios of fever of unknown origin, bacteremia, pneumonia, and gastroenteritis. RESULTS: Data on recommendations of nonpharmacologic anti-infective measures and infectious complications were available in 339 patients treated in 37 institutions. Analyses did not demonstrate a significant benefit of any of the restrictions regarding food, social contacts, and pets on the risk of fever, bacteremia, pneumonia, and gastroenteritis. In contrast, age, weight group, risk stratification, and nonabsorbable antibiotics had some influence on infections complications. CONCLUSION: The lack of effectiveness of dietary restrictions and restrictions regarding social contacts and pets should result in reconsideration of anti-infective policies.

[Not Available]. / Kasuistik - 44-jähriger Patient mit Fieber und Hautrötung in der Notaufnahme.

Skin and soft tissue infections may progress rapidly and take a fatal ending unless not treated in time. A 44-year old male patient without any pre-existing conditions got hospitalized with a bursitis ofthe right olecranon and unspecific general symptoms. Within a short period of time he became critically ill due this seemingly harmless infection. We describe our approach leading to the right diagnoses and the treatment of this unexpected progress.

Utilidad de la tomografía por emisión de positrones con 18F-Fluorodesoxiglucosa combinada con tomografía computarizada en la orientación diagnóstica de la fiebre de origen desconocido / Usefulness of 18FDG PET-CT scan as a diagnostic tool of fever of unknown origin

Fundamento y objetivo: La fiebre de origen desconocido (FOD) se define clásicamente como fiebre de más de 3 semanas, con temperatura superior a 38,3 °C en varias ocasiones y sin diagnóstico definitivo tras una semana de hospitalización. Determinar su etiología es fundamental para establecer un tratamiento adecuado del paciente. Nuestro objetivo es valorar la utilidad de la tomografía por emisión de positrones con 18F-Fluorodesoxiglucosa (18F-FDG) combinada con tomografía computarizada (PET/TC) con fluorodesoxiglucosa marcada con flúor 18 (18F-FDG) en la orientación diagnóstica de la FOD. Material y método: Estudio observacional retrospectivo de exploraciones PET/TC realizadas a 30 pacientes consecutivos con FOD entre marzo de 2010 y septiembre de 2013. El diagnóstico definitivo se alcanzó en 26/30 pacientes (86,67%): 15 con confirmación histológica, microbiológica en un caso y con seguimiento clinicorradiológico (media de 16,38 meses) en 10 pacientes. Resultados: Un total de 23 estudios fueron positivos: 10 con etiología tumoral, 8 inflamatoria, 4 infecciosa y uno miscelánea (100% verdaderos positivos). La PET/TC mostró una eficacia en el enfoque diagnóstico del 90,00%, una sensibilidad del 88,46% (intervalo de confianza del 95% [IC 95%] 76-101), una especificidad del 100,00% (IC 95% 100-100), un valor predictivo positivo del 100,00% (IC 95% 100-100) y un valor predictivo negativo del 57,14% (IC 95% 20-91). Conclusiones: La 18F-FDG PET/TC ha demostrado presentar una elevada sensibilidad y especificidad en el diagnóstico etiológico de la FOD, aportando una información morfofuncional valiosa, especialmente en la localización del lugar óptimo para la toma de biopsias (AU)

Background and objective: Classic fever of unknown origin (FUO) is defined as the presence of fever greater than 38.3 °C of at least 3 weeks with an uncertain diagnosis. Identification of the etiology is crucial in guiding further diagnostic procedures and subsequent patient management. The aim of this study was to evaluate the role of fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography combined with computed tomography (PET/CT) in the diagnostic orientation of FUO. Material and method: An observational retrospective study was performed, including 30 consecutive patients who had been studied between March 2010 and September 2013. Twenty-six out of 30 patients (86.67%) had a definitive diagnosis after pathologic confirmation in 15 cases, microbiological findings in one patient and clinical and radiological follow-up in 10 patients (mean: 16.38 months). Results: Among the positive scans, malignancy (n = 10), inflammatory (n = 8), infectious (n = 4) and miscellaneous causes (n = 1) were identified. 18F-FDG PET/CT had a diagnostic accuracy of 90.00%, sensitivity of 88.46% (95% confidence interval [95% CI] 76-101), specificity of 100.00% (95% CI 100-100), positive predictive values of 100.00% (95% CI100-100) and negative predictive value of 57.14% (95% CI 20-91). Conclusions: 18F-FDG PET/CT provided useful for the etiologic diagnosis of FUO, with high sensitivity and specificity.18F-FDG PET/CT has an incremental morphological and functional value, especially indicating the best biopsy site (AU)

[Fever and right upper abdominal pain in a 26-year-old returning from travel abroad]. / Fieber und rechtsseitige Oberbauchschmerzen bei einem 26-jährigen Reiserückkehrer.

Persistent fever and unspecific general symptoms need a complete and detailed medical history and search for infection. We report on a case of amebiasis with liver abscesses of a 26-year-old man. He had stayed several weeks in India and South America. After being free of complaints for 4 months, unspecific general symptoms and fever appeared. Due to proven liver abscesses, a combination treatment was given. Within 12 days, he was free of symptoms and could be discharged.

[A 55-year-old woman with cough, fever, swelling of joints, and exanthema after a trip to Ecuador]. / 55-jährige Patientin mit Husten, Fieber, Gelenkschwellungen und Exanthem nach einem Urlaub in Ecuador.

A 55-year-old woman presented 18 months after a trip to Ecuador with night sweat, malaise, and an unclear lesion of the lung. Computed tomography of the lung showed a nodular lesion of 14 mm. Antibodies against Histoplasma capsulatum were detected in the complement fixation text (CFT) and IgG western blot. Re-examination of a formalin fixed paraffin embedded (FFPE) lung-biopsy revealed yeasts after silver staining, compatible with H. capsulatum , which was verified by extraction and amplification of DNA from FFPE. After therapy with itraconazole 400 mg/day, the patient showed an uneventful clinical recovery without regression of the lung lesion. The serological follow-up examination after 17 months showed CFT without pathological findings.

[Fever, atrial fibrillation, and angina pectoris in a 58-year-old man]. / Fieber, Vorhofflimmern und Angina pectoris bei einem 58-jährigen Patienten.

Primary cardiac lymphoma (PCL) respresents a very rare type of cardiac tumour. This report illustrates a case of PCL in an immunocompetent 58-year-old man presenting with atrial fibrillation and febrile syndrome. Comprehensive imaging [computer tomography (CT), cardiac magnetic resonance imaging (cMRI), 3-dimensional transesophageal echocardiography (3D-TEE)] identified a large right atrial tumour, leading to pericardial effusion. Isolated cardiac involvement was confirmed by positron emission tomography (PET)-CT. A diffuse large B-cell lymphoma (DLBCL) was diagnosed based on the results of a TEE-guided biopsy. A normalized PET scan (PETAL study) indicated complete remission following R-CHOP 14 immunochemotherapy. Thus, an interdisciplinary and multimodal approach avoided unnecessary cardiac surgery.

[A 55-year-old man with abdominal pain and fever]. / 55-jähriger Patient mit abdominellen Schmerzen und Fieber.

A 55-year-old man was admitted for evaluation of chronic abdominal pain and fever. Computed tomography demonstrated a retroperitoneal inflammatory process involving the mesenteric root. Adipose tissue biopsy showed panniculitis mesenterica with granulomas. Further examinations confirmed the diagnosis of plasmocytoma type IgG kappa. Treatment with steroids (prednisolone), resulted in immediate improvement of pain and fever. Mesenteric panniculitis represents a paraneoplastic syndrome associated with non-Hodgkin lymphoma.

[Dyspnea and weight loss in a 70-year-old man]. / Dyspnoe und Gewichtsverlust bei einem 70-jährigen Patienten.

A 70-year-old man presented with subacute dyspnea, cough, weight loss, and mild fever. Blood analysis revealed an elevated C-reactive protein level. Chest x-ray and CT of the chest showed alveolar opacities with a migratory tendency during the clinical course. After extensive diagnostics, treatment with prednisolone under the presumed diagnosis of a cryptogenic organizing pneumonia was started, which lead to a rapid clinical response.

[Fever, leg swelling, coughing, and left upper quadrant pain in a 19-year-old woman]. / Fieber, Unterschenkelschwellung, Husten und linksseitige Oberbauchschmerzen bei einer 19-jährigen Patientin.

Persistent fever and unspecific general symptoms need a complete and thorough medical history and search for infection. We report on a case of brucellosis (Malta fever) with involvement of organs in a 19-year-old woman. She had previously lived on a farm in Portugal for several weeks, where she had consumed self-produced goat cheese. After a latency period of several months, unspecific general symptoms, fever, monarthritis, an increase of transaminases, and a newly diagnosed cardiac murmur became apparent. After the serologic and cultural proof of brucellosis, the patient underwent an antibiotic combination therapy. Within 20 days she was free of symptoms and could be released.

[A 22-year-old patient from Ghana with fever and reduced CD4 T-cell count]. / Fieber und erniedrigte CD4-Zellzahl bei einem 22-jährigen Patienten aus Ghana.

A 22-year-old patient from Ghana without relevant co-morbidities was admitted twice with fever of unknown origin and reduced CD4 T-cell count. During the second hospital stay, after prolonged incubation of blood cultures and detection of vegetations on the mitral valve in a transesophageal echocardiogram, infectious endocarditis with Aggregatibacter aphrophilus was diagnosed. Treatment according to European guidelines resulted in resolution of the fever, dissolution of the mitral valve vegetations and recovery of CD4 T-cell count.

Effectiveness of a Protective Environment implementation for cancer patients with chemotherapy-induced neutropenia on fever and mortality incidence.

In a quasiexperimental study conducted to evaluate the impact of a Protective Environment implementation, febrile neutropenia (P = .009), overall mortality (P = .001), and 30-day adjusted mortality (P = .02) were reduced in cancer patients with chemotherapy-induced neutropenia. Our study highlights the potential success of a set of prevention measures mainly designed to reduce invasive environmental fungal infections in allogeneic hematopoietic stem cell transplant patients, in reducing fever and mortality among neutropenic cancer patients.