Primary adrenal insufficiency due to bilateral adrenal hemorrhage-adrenal infarction in a patient with systemic lupus erythematosus and antiphospholipid syndrome: case presentation and review of the literature.

Primary adrenal insufficiency (PAI) is a rare disease which represents the end stage of a destructive process involving the adrenal cortex. Occasionally it may be caused by bilateral adrenal hemorrhagic infarction in patients with antiphospholipid syndrome (APS). We herein report the challenging case of a 30-year-old female patient with systemic lupus erythematosus (SLE) and secondary APS who was admitted to the emergency department (ED) due to fever, lethargy, and syncopal episodes. Hyponatremia, hyperkalemia, hyperpigmentation, shock, altered mental status, and clinical response to glucocorticoid administration were features highly suggestive of an acute adrenal crisis. The patient's clinical status required admission to the intensive care unit (ICU), where steroid replacement, anticoagulation, and supportive therapy were provided, with a good outcome. Imaging demonstrated bilateral adrenal enlargement attributed to recent adrenal hemorrhage. This case highlights the fact that bilateral adrenal vein thrombosis and subsequent hemorrhage can be part of the thromboembolic complications seen in both primary and secondary APS and which, if misdiagnosed, may lead to a life-threatening adrenal crisis. High clinical suspicion is required for its prompt diagnosis and management. A literature search of past clinical cases with adrenal insufficiency (AI) in the setting of APS and SLE was conducted using major electronic databases. Our aim was to retrieve information about the pathophysiology, diagnosis, and management of similar conditions.

Probiotics for the treatment of women with bacterial vaginosis.

This review considers whether probiotics are effective agents for the treatment and/or prevention of bacterial vaginosis (BV). There seems to be an association between the absence of, or low concentrations of, vaginal lactobacilli and the development of BV. Many studies have suggested that the presence of H2O2-producing vaginal lactobacilli may protect against BV, although some studies do not support this hypothesis. In-vitro studies have suggested that certain specific strains of lactobacilli are able to inhibit the adherence of Gardnerella vaginalis to the vaginal epithelium and/or produce H2O2, lactic acid and/or bacteriocins, which inhibit the growth of bacteria causing BV. Clinical trials showed that intra-vaginal administration of Lactobacillus acidophilus for 6-12 days, or oral administration of L. acidophilus or Lactobacillus rhamnosus GR-1 and Lactobacillus fermentum RC-14 for 2 months, resulted in the cure of BV (defined as a 0-1 positive score according to Amsel's criteria), and/or reduced the recurrences of BV, and/or caused an increase in vaginal lactobacilli and restoration of a normal vaginal microbiota, significantly more frequently than did a placebo, acetic acid or no treatment. However, several trials have found no significant difference in the cure rate of BV and in the number of vaginal lactobacilli after intra-vaginal instillation of lactobacilli when compared with the effect of a placebo or oestrogen. Thus, although the available results concerning the effectiveness of the administration of lactobacilli for the treatment of BV are mostly positive, it cannot yet be concluded definitively that probiotics are useful for this purpose.

Systematic review: are antibiotics detrimental or beneficial for the treatment of patients with Escherichia coli O157:H7 infection?

BACKGROUND: Escherichia coli O157:H7 is a foodborne pathogen causing haemorrhagic colitis, which is sometimes complicated by haemolytic uraemic syndrome or thrombotic thrombocytopenic purpura. AIM: To review the available evidence regarding the question of whether antibiotics are effective or harmful for the treatment of patients infected with E. coli O157:H7 infection. METHODS: We searched in the PubMed for relevant laboratory and clinical studies published between 1982 and 2005. RESULTS: In vitro studies have shown that most E. coli O157:H7 isolates are susceptible to various antibiotics, although certain antibiotics, especially at sublethal concentrations, have been found to increase the release of Shiga-like toxins, which have been associated with the development of haemolytic uraemic syndrome/thrombotic thrombocytopenic purpura in humans. No clinical studies have indicated that antibiotics are effective in reducing the duration of E. coli O157:H7 infection or the duration of diarrhoea or bloody diarrhoea specifically, while a few studies have supported that some antibiotics, especially quinolones and fosfomycin, may prevent the development of haemolytic uraemic syndrome or thrombotic thrombocytopenic purpura. On the other hand, there are some clinical studies that associate antibiotics with a higher risk for haemolytic uraemic syndrome and/or longer duration of diarrhoea, even with high mortality. CONCLUSIONS: More randomized controlled trials are necessary in order to elucidate whether antibiotics are effective in reducing the morbidity and mortality of E. coli O157:H7 infection, rather than having a detrimental effect.