When the Lightning Strikes Twice: Navigating the Complex Terrain of Cerebral Tuberculosis.

Tuberculosis (TB), a Mycobacterium tuberculosis (Mtb) infection, remains a significant global health concern despite a declining incidence. This report highlights a complex case involving a 24-year-old patient from Angola who presented with a constellation of symptoms, including fever, weight loss, and neurological deficits. The patient had been on chronic corticosteroid therapy, a known risk factor for the reactivation of latent TB infection (LTBI). Her clinical course was marked by diagnostic challenges, such as a previous diagnosis of Kikuchi's disease and paradoxical progression despite appropriate tuberculostatic chemotherapy. Miliary TB, characterized by widespread dissemination of Mtb from the primary site of infection, can manifest in various extrapulmonary locations. Central nervous system (CNS) involvement, particularly TB meningitis, is the most severe form of TB, associated with significant morbidity and mortality. The diagnosis of miliary and CNS TB can be elusive due to nonspecific clinical presentations and imaging findings. This case underscores the importance of a high index of suspicion, especially in immunocompromised individuals, and the need for comprehensive microbiological analysis, including cerebrospinal fluid (CSF) examination, to confirm CNS involvement. Furthermore, this case illustrates the challenges associated with TB treatment, including the risk of drug toxicity, medication adherence, and the potential for drug resistance. Treatment duration for miliary TB is extended, typically lasting nine months to a year, and may require adaptation based on the patient's clinical response and drug penetration into the CNS. Corticosteroids play a critical role as adjuvant therapy, particularly in cases with perilesional edema or paradoxical reactions during treatment. This case underscores the complexity of diagnosing and managing miliary and CNS TB, emphasizing the importance of considering TB as a diagnostic possibility in patients with nonspecific symptoms and risk factors. Early identification, multidisciplinary collaboration, and tailored therapeutic strategies are essential for achieving optimal outcomes in such challenging cases. Additionally, screening for latent TB infection should be a priority for patients requiring immunosuppressive therapy to mitigate the risk of reactivation.

Validation of the Acute Physiology and Chronic Health Evaluation (APACHE) II Score in COVID-19 Patients Admitted to the Intensive Care Unit in Times of Resource Scarcity.

Introduction During the coronavirus disease 2019 (COVID-19) pandemic, a high number of patients needed to be admitted to the intensive care units (ICUs). Such a high demand led to periods where resources were insufficient and the triage of patients was needed. This study aims to evaluate the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II as a predictor of mortality in periods where triage protocols were implemented. Methods A single-center, longitudinal, retrospective cohort study was performed on patients admitted to the ICU between January 2020 and December 2021. Patients were divided into two periods: Period 1 (where patients needing ICU admission outnumbered the available resources) and Period 2 (where resources were adequate). The discriminative power of the APACHE II was checked using the receiver operating characteristic (ROC) curves. Calibration was accessed, and survival analysis was performed. Results Data from 428 patients were analyzed (229 in Period 1 and 199 in Period 2). The area under the ROC curve (AUROC) was 0.763 for Period 1 and 0.761 for Period 2, reflecting a good discriminative power. Logistic regression showed the APACHE II to be a significant predictor of mortality. The Hosmer-Lemeshow test demonstrated good calibration. The Youden index was determined, and a log-rank test showed a significantly lower survival for patients with higher APACHE II scores in both periods. Conclusions The APACHE II score is an effective tool in predicting mortality in patients with COVID-19 admitted to the ICU in a period where resource allocation and triage of patients are needed, paving a way for the future development of better and improved triage systems.

Shewanella algae, an Emerging Human Pathogen: A Series of Four Cases From a Portuguese Hospital.

Shewanella algae is a rod-shaped, Gram-negative bacterium that is considered an emerging human pathogen. Traditionally associated with warmer climates, S. algae has now been isolated from patients worldwide, and reports of infection are increasing. In a regional hospital on the outskirts of Lisbon, Portugal, four cases have been detected in the past 10 years. Two of the patients were migrants from African countries with daily contact with water; the other two patients were Portuguese, and no epidemiological risk factors were found among them. These are the first cases reported in Portugal. Risk factors associated with S. algae infection in patients discussed in this paper include the following: human immunodeficiency virus (HIV) infection, chronic venous insufficiency, lower limb ulcers, chronic kidney disease, diabetes, arterial hypertension, dilated cardiomyopathy, atrial fibrillation, chronic hepatic disease, and chronic pancreatitis. One patient died in the intensive care unit with septic shock and disseminated intravascular coagulation from a fulminant infection secondary to S. algae bacteraemia. The four clinical cases presented in this case series highlight the clinical features of this infection so that other physicians can successfully identify and treat S. algae infections.