Abscesos cerebrales: análisis de factores pronóstico e influencia del tratamiento antibiótico protocolizado en su evolución / Brain abscess. Evaluation of prognostic factors: does the use of antibiotic prescribing protocols improve outcome?

Objetivos: Analizamos los factores pronósticos asociados a mortalidad en pacientes con absceso cerebral (AC) y la influencia del tratamiento antibiótico protocolizado (PA). Pacientes y Métodos: estudio observacional en un hospital universitario (1975-2005). El tratamiento antibiótico empírico se realizó sin PA (Periodo I -PI-, 1975-1983; n = 33) y de acuerdo a PA diseñado por los Servicios de MI-Infecciosas y Neurocirugía a partir de 1983 (Periodo II -PII-; n = 71); valoramos la influencia del Protocolo Terapéutico en la curación de los enfermos. Resultados: se evaluaron 104 pacientes (edad media 45 años; rango12-86); el origen del AC se identificó en 89% y en 76% hubo confirmación microbiológica. Mortalidad, 16,3% (17/104); se asociaron de forma estadísticamente significativa a mayor mortalidad: edad > 40 años, enfermedad de base últimamente fatal, situación clínica inicial crítica-mala, presencia de alteración del estado de conciencia y tratamiento empíricono adecuado. No hubo diferencias estadísticamente significativas en las características epidemiológicas, clínicas, radiológicas o microbiológicas de los pacientes correspondientes al PI y al PII, excepto en edad (> 40años, 36% en PI y 62% en PII); si hubo diferencias en curaciones, 60% vs 77% (p < 0,05); recidivas 21 vs. 7% (p < 0,05) y mortalidad 18 vs.15,4% (p > 0,05) en PI y PII, respectivamente. Conclusiones: La edad, enfermedad de base últimamente fatal, gravedad clínica inicial, presencia de alteración del nivel de conciencia y el tratamiento antibiótico empírico inadecuado son los principales factores pronósticos asociados a mayor mortalidad en pacientes con AC. La prescripción del tratamiento empírico de acuerdo con un PA consensuado se asoció con mayor porcentaje de curaciones y menor número de recidivas

Background: the aim of this study was to evaluate prognostic factors in brain abscess (AB) and influence of management with antibiotic prescribing protocols (APP). Patients and Methods: observational study of a cohort of non-paediatric patients with BA admitted at a 944-bed hospital (1976-2005). Data collection from clinical records has been done according to a standard protocol. We analysed epidemiological, clinical, radiological, microbiological and laboratory data associated with mortality. From1976 to 1983 (Period I), antibiotic treatment was not done according toany internal APP; from 1983 (Period II), antibiotic management was done according to a APP designed by infectious diseases specialists and neurosurgeons. Predictors of mortality were identified by univariate analysis. The influence of the use of APP in outcome was assessed. Results: 104 patients with BA were included (mean age 45 years;range 12-86); presumed primary pathogenic mechanism of BA was identified in 89%; microbiologic diagnosis was made in 76%. Overall mortality was 16.3%. Factors statistically associated with higher mortality were: age > 40 years, ultimately fatal underlying disease, acute severe clinical condition at the onset of BA, altered mental status and inadequate empirical treatment; 33 patients were treated in Period I and 71 in Period II; no statistically significant differences were found between epidemiological, clinical, radiological or microbiological characteristics of the groups except for mean age (> 40 years in 36% and 62% respectively in Period I and II). Rates of resolution of BA were 60 vs. 77.4% (p <0.05); relapses 21 vs. 7% (p < 0.05) and mortality 18 vs. 15.4% (p >0.05), in Period I and II respectively. Conclusions: main prognostic factors associated with mortality in patients with BA are age, rapidly fatal underlying disease, acute severe clinical condition at the onset of BA, altered mental status and inadequateempirical treatment. Empiric treatment according to APP was associated with greater resolution and lower relapse rates

Litiasis salival en la infancia / Salivary calculi in children

Introducción. Las glándulas salivales principales son la submaxilar, sublingual y la parótida. La patología infecciosa y tumoral predomina en la parótida mientras que la litiásica en las glándulas submaxilar (mayor frecuencia) y sublingual. Material y método. Nuestro trabajo consistió en la revisión de 18 casos con diagnóstico de litiasis salival, tratados en nuestro Servicio en los últimos 13 años. Se compararon la forma de presentación, métodos de diagnóstico (ecografía, sialografía y TC), tratamiento y evolución de los mismos. Resultados. Los pacientes estudiados (de edades comprendidas entre 4-16 años) fueron hombres en 13 casos y mujeres en 5. Clínicamente presentaron cuadro de dolor y tumefacción. De los 10 casos con afectación de glándula parótida, en el 70% se demostró origen infeccioso y fueron catalogados posteriormente de parotiditis crónica; el 30% tenía verdadera litiasis (3 casos). Seis casos correspondieron a glándula submaxilar y 2 casos a glándula sublingual. La litiasis salival se presentó, por lo tanto, con mayor frecuencia en la glándula submaxilar. El tratamiento quirúrgico estuvo indicado en el 100% de los pacientes con patología litiásica y consistió en la apertura del conducto excretor y extracción del cálculo. Se realizó tras remisión del cuadro inflamatorio inicial con antibioterapia y antiinflamatorios. En el seguimiento se constató una buena evolución postoperatoria en todos los casos y no hubo recidivas. Conclusiones. La historia clínica, la exploración minuciosa y las técnicas por imagen permiten establecer el diagnóstico de litiasis salival. El tratamiento es quirúrgico y debe realizarse de manera diferida tras el tratamiento médico del cuadro inflamatorio (AU)

The main salivary glands are the submaxillary, sublingual and parotid glands. Infectious and tumoral conditions are prominent in the parotid gland whilst calculi are in submaxillary and sublingual glands. METHODS. Medical record review of 18 cases with a diagnosis of salivary calculi over a 13 year period. Data collected consisted in, clinical presentation, ultrasound (US), sialography (SG) and computarized tomography (CT), and treatment. RESULTS: 13 male and 5 female.Mean age was 7.2 years. All of them presented with pain and tenderness. Parotid gland was affected in 10 cases. An infectious cause for calculi was found in 7 while 3 presented calculi with no underlying infectious cause. Submaxillary gland was affected in 6 and sublingual in 2. No infectious condition was associated to submaxillary and sublingual calculi. Surgical treatment consisted in duct canalization for calculi removal and was performed in all patients after initial treatment with antibiotics. Neither complications nor relapse was found after surgical removal. CONCLUSIONS: Diagnosis of salivary calculi is made by clinical symptoms and imaging exams. Treatment is surgical and has to be performed after medical treatment for infection and inflammation (AU)

Actualización en antibioterapia / Up-dates in antibiotic treatment

Objetivo: Se trata de un artículo de revisión que pretende una puesta al día en el problema de las resistencias bacterianas a los antibióticos, que todos los que desarrollan su actividad en el ámbito pediátrico deben conocer. Desarrollo: La resistencia a antibióticos es un problema de salud pública, que ha experimentado un elevado incremento en los últimos años, y España es uno de los países europeos más afectados. El consumo de antibióticos, especialmente elevado en población pediátrica, es la principal causa de este incremento. Los factores que determinan su consumo son variados: estilo de práctica médica, medicina defensiva, presión asistencial, automedicación, presión farmacéutica, políticas sanitarias, entre otros. Es necesario establecer estrategias que nos permitan reducir el impacto sanitario de las resistencias bacterianas. Conclusiones: El conocimiento de las tendencias evolutivas en el consumo y la situación de la resistencia a antibióticos debe ser el primer paso que nos permita evaluar el consumo realizado y examinar los factores que en él han intervenido, con el fin de concretar áreas de mejora en el uso de los antibióticos y valorar el efecto de determinadas intervenciones modificadoras y de contención (AU)

Objective: It is a question of an article of review that he claims a putting a day in the problem of the bacterial resistance to antibiotics, that all those who work with children must know. Development: Antibiotic resistance is a public health problem that has become increasingly acute in last years and Spain is one of the most affected European countries. Antibiotic consumption specially elevated in paediatric population, is the main cause of this emerging resistance. The determinants of antibiotic use are varied: style of medical practice, defensive medicine, welfare pressure, self-medication, pharmaceutical pressure, sanitary policies, among others. It is necessary to establish strategies that allow reducing the sanitary impact of the bacterial resistances. Conclusions: The knowledge of the tendencies in the consumption and the situation of the antibiotics resistances must be the first step that allows to evaluate the consumption and to examine the factors that have intervention, with the purpose of making specific areas of improvement in the antibiotic use and to value the effect of some modifiers and containment interventions (AU)

Estudio controlado con grupos paralelos y abierto de la eficacia clínica y microbiológica de piperacilina-tazobactam frente a metronidazol más gentamicina en cirugía colorrectal urgente / Controlled, open, parallel-group study of the clinical and microbiological efficacy of piperacillin-tazobactam versus metronidazole + gentamicin in urgent colorectal surgery

Introducción. El tratamiento antibiótico es un elemento importante para el control de la infección postoperatoria en la cirugía abdominal de urgencias. El objetivo de este estudio consiste en determinar la eficacia terapéutica del tratamiento con piperacilina-tazobactam frente a la combinación de dos antibióticos (metronidazol más gentamicina) en pacientes intervenidos de cirugía colorrectal y apendicular urgente. Pacientes y método. El período de estudio comprendió de diciembre de 1998 a diciembre de 2002. Se incluyó de forma prospectiva y aleatorizada a un total de 183 pacientes que requirieron cirugía de urgencia por presentar afecciones en el colon y/o apendicitis aguda grave. Los pacientes se han distribuido en dos grupos de forma aleatoria. Grupo A: piperacilina-tazobactam (4/0,5 g/8 h por vía intravenosa [i.v.]), y grupo B: metronidazol (500 mg/8 h/i.v.) más gentamicina (5 mg/kg/24 h/i.v.). El tratamiento se inició entre 30 y 60 min antes de la intervención quirúrgica y se administró durante un mínimo de 3 días. Resultados. Los pacientes intervenidos de cirugía del colon y de apendicitis aguda presentaron una menor incidencia de infección de la herida quirúrgi-ca cuando se los trató con piperacilina-tazobactam (p < 0,05). En el grupo de pacientes intervenidos de afección apendicular se objetivó una menor incidencia de abscesos intraabdominales cuando fueron tratados con piperacilina-tazobactam. Tras el análisis microbiológico de los cultivos, se observa que existe un predominio de infección por Escherichia coli. Conclusiones. La asociación de piperacilina-tazobactam se ha mostrado más eficaz que la asociación metronidazol-gentamicina en la prevención y el tratamiento de infecciones locales en los grupos tratados. El fracaso terapéutico se asocia principalmente a gérmenes gramnegativo (AU)

Introduction. Antibiotic treatment is an important element in infection control after urgent abdominal surgery. The aim of this study was to determine the therapeutic efficacy of piperacillin-tazobactam versus a combination of 2 antibiotics (metronidazole and gentamicin) in patients undergoing urgent appendicular and/or colorectal surgery. Patients and method. The study period comprised December 1998 to December 2002. A total of 183 patients who required urgent surgery for colon disease and/or severe acute appendicitis were prospectively and randomly included. Patients were randomly distributed in 2 groups. Group A received piperacillin-tazobactam (4/0.5/8 h/iv) and group B received metronidazole (500 mg/iv/ 8 h) plus gentamicin (5 mg /kg/iv/24 h). Treatment was started between 30 and 60 minutes prior to surgery and was continued for at least 3 days. Results. The incidence of wound infection in patients who underwent surgery for colon disease and acute appendicitis was lower when they were treated with piperacillin-tazobactam (P<.05). The incidence of intraperitoneal abscess in the group of patients who underwent surgery for severe acute appendicitis was lower when they were treated with piperacillin-tazobactam. Microbiological analyses revealed that there was a predominance of infection due to Escherichia coli. Conclusions. The association of piperacillin-tazobactam was more effective than that of metronidazole and gentamicin in the prevention and treatment of local infection in the treated groups. Therapeutic failure was mainly related to the presence of Gram-negative bacteria (AU)

Histerectomía: profilaxis antibiótica y de la enfermedad / Hysterectomy. Antibiotic and thromboembolic prophylaxis

Profilaxis antibiótica. El uso profiláctico de antibióticos en la histerectomía, está plenamente justificado debido al elevado riesgo de morbilidad infecciosa que habitualmente se registra en el postoperatorio de esta técnica quirúrgica en todas sus modalidades; este hecho es especialmente significativo en aquellos casos en los que no se practicó la administración profiláctica de antibióticos. El análisis de las diversas vías de abordaje en la histerectomía, los microorganismos existentes en el ecosistema vaginal, los factores de riesgo relacionados con estos procedimientos quirúrgicos, las complicaciones infecciosas descritas y sobre todo la eficacia de la profilaxis antibiótica, demuestran sin ningún género de dudas la trascendencia del tema. Profilaxis de la enfermedad tromboembólica. Debe ser una práctica habitual debido a la incidencia de la misma y el efecto beneficioso de su administración. Es esencial evaluar los factores de riesgo pre e intraoperatorios a la hora de su prescripción

Antibiotic prophylaxis. Use of antibiotic prophylaxis in patients undergoing elective hysterectomy is widely justified due to the high rate of postoperative infections registrated when it is not applied. When we analized route of hysterectomy, organisms colonized the vagina, risk factors related with surgery, infectious complications and efficacy of the antibiotic prophylaxis, there is not any doubt about the importance of this matter. Thromboembolic prophylaxis. Thromboembolic prophylaxis is mandatory due to its incidence and the high efficacy of its treatment. It is important to evaluate risk factors associated to each case before its prescription

Osteomielitis occipito-atlantoidea secundaria a otitis externa maligna / Occipitoatlantoidal osteomyelitis secondary to malignant otitis externa

La otitis externa maligna es una infección poco frecuentepero potencialmente muy grave. Puede diseminarse haciabase de cráneo, siendo rara la afectación de la unióncráneo-vertebral. Su diagnóstico requiere un alto índicede sospecha. Las técnicas de imagen son útiles en eldiagnóstico y seguimiento, pero ninguna es definitiva. Eltratamiento de elección consiste en antibióticosantipseudomona. El desbridamiento amplio de los tejidosha sido relegado por la aparición de nuevas opcionesterapéuticas. Presentamos el caso de un pacientevarón de 87 años, sin antecedentes remarcables, quedesarrolla otitis externa maligna de oído izquierdo, quese complica con parálisis facial y glosofaríngea, extendiéndosehacia la base de cráneo y llegando a afectar a laarticulación occipito-atlantoidea. El paciente recibió tratamientoantibiótico durante 8 semanas, cediendo la afectacióndel estado general, pero persistiendo la parálisisfacial

Malignant otitis externa is an uncommon butpotentially serious infection. It can spread to the skullbase but the craniovertebral junction involvement israre. Diagnosis of malignant otitis externa demands ahigh index of suspicion. Radiological images are usefulin the diagnosis and monitoring of the disease butnone of them is definitive. The main treatment isantipseudomonal antibiotic. Wide tissue debridementhas been changed because of the presence of newtherapeutic options.We report a 87-year-old man with unremarkablemedical history who developed a left malignant otitisexterna that complicated with facial andglossopharyngeal palsy. After that the infection spreadedto the skull base and it affected the craniovertebraljunction. The patient underwent antibiotic treatmentduring 8 weeks, with clinical condition improvement butfacial palsy persistence

[Nocardia brasiliensis leg ulcer and nodular lymphangitis in France]. / Ulcère de jambe et lymphangite nodulaire à Nocardia brasiliensis en France métropolitaine.

INTRODUCTION: Nocardia brasiliensis is a very rarely reported cause of chronic phagedenic ulcerations. We report the case of an elderly woman who developed such an infection after falling on her right leg on the road in the Bresse country (an essentially agricultural and bovine-cattle breading region) and developed a chronic phagedenic ulcer secondarily complicated by nodular lymphangitis of the thigh. CASE REPORT: A 75 year-old woman fell on her right leg on the side of the main road outside her hamlet in the Bresse country and secondarily developed a chronique phagedenic ulceration. We first considered her as suffering from pyoderma gangrenosum. A complete scanning only revealed an autoimmune thyroiditis and a rapidly healing gastric ulceration, and none of the treatments, either local or systemic, helped the skin condition to heal. After 3 weeks of application of a local corticoid ointment, the patient developed fever, general malaise, an exacerbation of her wound and an infiltration of the skin round her knee, together with nodular lymphangitic dissemination. A supplementary bacterial swab disclosed massive proliferation of a slow-growing Gram-positive bacillus, which proved to be Nocardia brasiliensis, together with a methicillino-sensitive Staphylococcus aureus. The treatment with sulfamethoxazole-trimetoprim gave a rash after 12 hours and was changed to amoxicillin and clavulanic acid, which rapidly proved to be permanently effective. DISCUSSION: The revelation of this particular slow-growing bacteria is difficult and requires bacterial swabs. Nocardia brasiliensis is relatively rare in primary skin ulcerations and we discuss the reasons why an elderly women should find this bacteria on the road outside her hamlet in the French countryside. This particular infectious condition requires general scanning, to make sure that the primary skin condition does not extend to other organs. We review the therapeutical options for patients who exhibit allergic reactions to the classically effective antibiotic drugs.

Treatment outcomes after pars plana vitrectomy for endogenous endophthalmitis.

PURPOSE: To evaluate the causative organisms of and predisposing medical conditions in endogenous endophthalmitis and review visual acuity after pars plana vitrectomy. METHODS: Records of 23 patients (32 eyes) who were diagnosed with endogenous endophthalmitis and treated at Shanghai Eye, Ear, Nose & Throat Hospital from January 2000 to December 2003 were retrospectively reviewed. Final visual acuity was followed up. RESULTS: Of these 23 patients, 19 (86%) had endogenous endophthalmitis confirmed with a positive smear or culture; 12 cases (63%) were due to fungi, 6 (32%) were due to bacteria, and 1 (5%) was a mixed infection (fungus and bacteria). Culture specimens from four patients, which were obtained by vitrectomy, were all positive, while their initial vitreous needle biopsy specimens were negative. Of the 20 eyes that underwent pars plana vitrectomy, 17 (85%) had anatomical success, and 16 (80%) gained visual acuity of counting fingers or better; of these eyes, 8 (40%) had visual acuity of 20/200 or better. CONCLUSION: Fungi, especially Candida albicans, were the most common causative organisms. The most common predisposing medical conditions were recent tumor surgery and intravenous administration in rural settings. Most patients with endogenous endophthalmitis who undergo pars plana vitrectomy will have useful vision (counting fingers). Vitreous specimens for culture that were obtained by vitrectomy were more sensitive in detecting the causative organism.

Subconjunctival antibiotics in the treatment of endophthalmitis managed without vitrectomy.

PURPOSE: To determine if the treatment outcomes for endophthalmitis are influenced by subconjunctival antibiotics. METHODS: A retrospective, nonrandomized consecutive series of patients with clinically diagnosed bacterial endophthalmitis confirmed with positive cultures who presented between December 1, 1995, and February 28, 2002, was studied. Patients with cataract surgery, glaucoma filtering blebs, or trauma who presented with visual acuity of hand motions or better were included. All patients received intravitreal and topical antibiotics. Management by pars plana vitrectomy or vitreous tap and use or nonuse of subconjunctival antibiotics were at the discretion of the treating physician. RESULTS: There were 59 patients identified; 54 met the follow-up criteria. These patients were divided into two groups based on whether subconjunctival antibiotics were used (group ABX; n = 21) or not used (group noABX; n = 33). The median pretreatment visual acuity was hand motions in both groups. The median age in both groups was 74 years. Etiology, duration of symptoms, vitreous culture organisms, percentage of cases with wound complications such as leaks or vitreous incarceration, and intraocular lens type were similar in the two study groups. Intravitreal and topical antibiotics and corticosteroids used were not significantly different in the two groups, except that topical ceftazidime was used less frequently in group ABX than in group noABX (43% vs. 82%, respectively; P = 0.007). The median follow-up was 13 months in both groups (range: 3-87 months for group ABX and 3-63 months for group noABX). Final visual acuity in groups ABX and noABX was at least 20/50 (33% vs. 39%, respectively), 20/60 to 5/200 (29% vs. 39%, respectively), 4/200 to better than hand motions (0 vs. 3%, respectively), or hand motions or worse (38% vs. 18%, respectively). These differences were not significant (P = 0.37). Reinjection rates (14% vs. 15%, respectively) were also similar in groups ABX and noABX. The additional procedures rate was significantly higher in group ABX than in group noABX (P = 0.024), with cumulative rates of 33% and 3%, respectively, at the 12-month follow-up. CONCLUSIONS: These data suggest that subconjunctival antibiotics may not be necessary to treat infectious endophthalmitis managed with otherwise standard tap and injection techniques and topical antibiotics.

Successful treatment of Fusarium endophthalmitis with voriconazole and Aspergillus endophthalmitis with voriconazole plus caspofungin.

PURPOSE: To report successful treatment of exogenous Fusarium and Aspergillus endophthalmitis with new antifungal agents. DESIGN: Interventional case report. METHODS: Treatment of two cases is reviewed. RESULTS: A 64-year-old man developed post-cataract Fusarium moniliforme endophthalmitis. Infection persisted despite removal of the intraocular lens, three vitrectomies, and five intravitreal injections of amphotericin. Inflammation resolved and vision improved from 20/80 to 20/40 on 6 months of oral voriconazole. A 55-year-old man developed post-cataract intraocular inflammation. After three vitrectomies and removal of the intraocular lens, Aspergillus fumigatus endophthalmitis was diagnosed. Intravitreal amphotericin and systemic voriconazole were given, but one week later there were early signs of recurrence. Intravenous caspofungin was added and the eye improved. Caspofungin was continued for 6 weeks and voriconazole for 6 months. Vision improved from counting fingers to 20/80 at 6 months and 20/25 at 23 months. CONCLUSION: Voriconazole is a promising new therapy for Fusarium and Aspergillus endophthalmitis. Caspofungin may act synergistically with voriconazole in treating Aspergillus endophthalmitis.

Renal hypersensitivity vasculitis associated with dapsone.

We describe clinical and pathological features of kidney and skin involvement in a patient with hypersensitivity vasculitis associated with dapsone. Although visceral damage occurs rarely, similar skin and kidney histopathologic and immunohistochemical findings indicate that this organ is a target for type IV cell-mediated dapsone reaction. To our knowledge, this is the first reported case of renal hypersensitivity vasculitis associated with dapsone.

Acinetobacter and Staphylococcus aureus ulcerative keratitis after laser in situ keratomileusis treated with antibiotics and phototherapeutic keratectomy.

PURPOSE: To report a method of treatment for through-the-flap multibacterial ulcerative keratitis after laser in situ keratomileusis (LASIK). METHODS: Bacterial ulcerative keratitis after LASIK was treated with topical and systemic antibiotics followed by flap lifting, cleaning, and phototherapeutic keratectomy (PTK). Follow-up examinations included in vivo confocal microscopy, corneal topography, and wavefront analysis. RESULTS: Rapid recovery of the ulcerative keratitis was observed after flap lifting and cleaning of the interface and PTK combined with topical and systemic antibiotics. Two years postoperatively, corneal topography showed a slight depression of the ulcer area and decentration of the photoablation. Wavefront analysis revealed an irregular scan with a pronounced coma-like aberration, which with a wavefront-guided custom test lens correction provided 20/16 visual acuity. CONCLUSIONS: Ulcerative bacterial keratitis is a possible sight-threatening complication of LASIK refractive surgery. Lifting and rinsing the flap combined with cleaning of the flap interface with PTK may be helpful in these conditions when regression of the ulcer does not occur with topical and oral antibiotic treatment.

Inflammatory pseudotumor of the liver revealing gynecological Corynebacterium infection.

Inflammatory pseudotumor (IPL) of the liver is a rare benign clinicopathologic entity, which has been associated with infectious conditions, including alimentary, digestive tract and mouth infections. We report a new case, where a patient developed hepatic IPL that revealed endometritis related to Corynebacterium infection; the patient had a favorable outcome of hepatic IPL after appropriate antibiotic therapy initiation. Our findings therefore confirm that antibiotic therapy may be effective in patients with hepatic IPL associated with underlying infections, avoiding unnecessary surgery. Our data also indicate that when hepatic IPL is observed, a complete clinical evaluation, including gynecological evaluation, should be systematically performed.

[Endoscopic ultrasound (EUS) in initial assessment and follow-up of patients with MALT lymphoma treated drug therapy].

BACKGROUND: Endoscopic ultrasonography (EUS) is an important tool for diagnosis and pretreatment staging of primary gastric lymphoma. The aim of the study was to evaluate the diagnostic importance of endosonography (EUS) in gastric lymphoma; to assess the depth of tumoral infiltration in low-grade gastric lymphoma of mucosa-associated lymphoid tissue (MALT) and to assess EUS response to medical treatment (Cyclophosphamid/Mabtera and/or anti-Helicobacter pylori therapy). METHODS: 26 patients with MALT gastric lymphoma were investigated by EUS. Six of them were evaluated after the eradication of Helicobacter pylori infection and 20 after and during the cyclophosphamide/Mabtera and anti H. pylori treatment. EUS staging was compared with histopathology. Tumours were staged according to the 2000 TNM and modified Ann Arbor classification. RESULTS: Six patients were treated with anti - Helicobacter pylori eradication therapy. Full regression of lymphoma was observed in 2 of 6 (33.3%) patients, which was endoscopicaly and histologicaly proved. EUS correlated with histology in all (6/6). In 20 patients treated with cyclophosphamide/Mabtera therapy, EUS revealed regression of lymphoma in 14 cases. Positive correlation with histology was found in 11 patients (11/14; 78%). The initial EUS showed an increased wall thickness more than 5mm in 24 of 26 patients (92%). The thickening was predominantly of mucosa and submucosa and in 11 patients extended the muscularis propria. After the therapy, the gastric wall thickening returned to normal in 14 patients, however, 3 of them still had positive histology findings. In 2 cases, during the follow-up, the EUS showed remained thickening of gastric wall, whereas biopsies were negative. Six months later histology revealed progressive low-grade MALT lymphoma in this cases. CONCLUSION: EUS appears to be a sensitive procedure for initial staging and assessment of treatment response and long-term follow up in patients with gastric lymphoma. The importance of EUS lies in abbility to detect relapse early, too.

Interleukin-12 and -18 levels in peritoneal dialysate effluent correlate with the outcome of peritonitis in patients undergoing peritoneal dialysis: implications for the Type I/Type II T-cell immune response.

BACKGROUND: We previously showed that a positive impact of peritoneal defense response on the outcome of peritoneal dialysis (PD)-related peritonitis is characterized by an increased pattern of peritoneal CD4/CD8 T-cell ratio with a predominant CD4(+)-T helper subtype 1 phenotype. To further explore longitudinal changes in peritoneal immunity during PD-related peritonitis, we examined the production of interleukin 12 (IL-12), IL-18, and interferon gamma (IFN-gamma) in peritoneal dialysate effluent (PDE) and kinetic expression of the transcription factors T box expressed in T cells (T-bet) and guanine adenine thymine adenine (GATA) binding protein 3 (GATA-3) in peritoneal T cells during peritonitis. Correlations between these observations and responses to antibiotics were analyzed. METHODS: IL-12, IL-18, and IFN-gamma protein and IFN-gamma, T-bet, and GATA-3 messenger RNA (mRNA) were measured in PDE during various phases of peritonitis in 40 patients undergoing PD. Patients were divided into 2 groups according to whether they had a rapid versus delayed response to antibiotic treatment. RESULTS: In the early phase of peritonitis, IL-12, IL-18, and IFN-gamma levels in PDE were significantly greater in the rapid-response group (P < 0.05). Changes in peritoneal IL-12 and IL-18 levels preceded changes in IFN-gamma levels. The kinetics of IFN-gamma, T-bet, and GATA-3 mRNA expression in peritoneal T cells, measured by means of real-time polymerase chain reaction, differed between the 2 groups. In the rapid-response group, IFN-gamma and T-bet mRNA expression increased, whereas that of GATA-3 decreased over time. Results were opposite in the delayed-response group, with IFN-gamma and T-bet levels decreasing and GATA-3 levels increasing over time. CONCLUSION: These data suggest that local IL-12 and IL-18 production is part of a protective early immune response to PD-related peritonitis. High IL-12 and IL-18 levels in PDE during the early phase of peritonitis correlated with a predominant type 1 immune response and favorable outcome.

An unusual presentation of tropical pyomyositis.

Tropical pyomyositis is a primary pyogenic infection of skeletal muscle, often caused by Staphylococcus aureus. The most common presentation of tropical pyomyositis is that of multiple acute abscesses with fever. Hepatitis is a rare manifestation of this disease. We report a case of tropical pyomyositis who presented with hepatic encephalopathy leading to initial diagnostic dilemma.