Daptomycin-Associated Diarrhea: A Case Report and Review of the Literature.

Antibiotic-associated diarrhea (AAD) describes any unexplained diarrhea associated with the use of antibiotics. AAD develops through diverse mechanisms, ranging from pharmacologic effects on gut motility to disturbance of the function and carbohydrate metabolism of the indigenous intestinal flora and overgrowth by pathogenic micro-organisms. Clostridioides difficile-associated diarrhea (CDAD) is a subset of AAD; however, it accounts only for a small percentage of diarrhea caused by antibiotics. Diarrhea has been reported as a side effect of daptomycin use, nevertheless, it's thought to be mild and carries significantly less risk of diarrhea than other alternative treatments of S. aureus bacteremia, i.e., vancomycin or cefazolin. The authors present an interesting case of daptomycin-associated diarrhea presenting with a protracted and severe course. Patient symptoms didn't improve with empiric Clostridioides difficile therapy and CDAD testing was negative. Diarrhea promptly resolved after discontinuation of daptomycin. Furthermore, a thorough literature review was conducted and discussed in this article to raise awareness of this under-recognized complication. Clinicians should be mindful of daptomycin-associated diarrhea along with its presentation and treatment. Further studies are needed to identify the pathophysiology of daptomycin-associated diarrhea and other forms of AAD. Understanding their mechanism could help prevent, treat, and reduce the significant medical costs associated with antibiotic adverse events.

Omental Fat Torsion: A Rare Mimicker of a Common Condition.

Acute abdomen is a common emergency condition affecting young adults, and the first consideration is usually aimed to rule out acute appendicitis in this age group. Omental fat torsion has emerged as one of the rare etiologies of acute abdomen in the younger population. It warrants serious consideration as it closely mimics acute appendicitis in its clinical presentation. Herein we report a case of omental fat torsion in a 22-year-old male patient who presented with an acute right-sided lower abdominal pain which was highly suggestive of acute appendicitis. However, the diagnostic laparoscopy revealed a normally looking appendix and terminal ileum with an infarcted omental segment on the right side of the greater omentum. A laparoscopic omentectomy and an appendectomy were performed with an uneventful postoperative recovery. The pathology report confirmed omental fat infarction and a normal appendix. This case highlights omental fat infarction as a rare etiology of acute abdomen in a young male patient.

Recurrent renal abscess complicating Staphylococcus saprophyticus infection in an immunocompetent young female patient: A case report and review of literature.

Staphylococcus saprophyticus is second only to Escherichia coli as the most frequent causative organism of uncomplicated urinary tract infections (UTIs) among the sexually active female population. However, it is considered a rare cause of complicated UTIs in immunocompetent hosts with no identifiable risk factors for the occurrence of a complicated urinary tract infection. We report an exceedingly rare case of a 20-year-old otherwise healthy female patient, with no identifiable risk factors for complicated UTIs, who presented with a recurrent renal abscess secondary to S. saprophyticus. Serial cultures from multiple sources were negative, and the culprit organism was identified by a polymerase chain reaction (PCR) analysis of the drained pus that identified the 16 s rDNA sequences of S. saprophyticus on serial occasions. To our current date, similar cases have been rarely reported in the available literature. Our case also highlights the diagnostic value of molecular biology techniques in the identification of causative pathogens in cases of culture-negative infections when conventional microbiologic tests fail to isolate the culprit organisms. Clinical microbiology studies are needed to further explore the exact possible interactions between bacterial-specific characteristics and host-related factors that may explain the occurrence of the complicated UTIs that are associated with S. Saprophyticus among patients who are not considered to have certain risk factors that would usually predispose to complicated UTIs.

Prevalence, Length of Stay, and Hospitalization of Acute Kidney Injury in Patients With and Without Sjogren's Syndrome.

BACKGROUND: Literature on the outcome of acute kidney injury (AKI) in Sjogren's syndrome (SJS) is quite scanty. Acute kidney injury has emerged as a significant cause of morbidity and mortality in patients with autoimmune diseases such as systemic lupus erythematosus. OBJECTIVE: To examine the outcome of AKI with and without SJS. To achieve this, we examined the prevalence, mortality, outcomes, length of stay (LOS), and hospital charges in patients with AKI with SJS compared with patients without SJS from a National Inpatient Sample (NIS) database in the period 2010 to 2013. DESIGN: A retrospective cohort study using NIS. SETTING: United States. SAMPLE: Cohort of 97 055 weighted patient discharges with AKI from the NIS. MEASUREMENTS: Not applicable. METHODS: Data were retrieved from the NIS for adult patients admitted with a principal diagnosis of AKI between 2010 and 2013, using the respective International Classification of Diseases, Ninth Revision (ICD-9) codes. The study population divided into 2 groups, with and without Sjogren's disease. Multivariate and linear regression analysis conducted to adjust for covariates. We omitted patients with systemic sclerosis and rheumatoid arthritis from the analysis to avoid any discrepancy as they were not meant to be a primary outcome in our study. RESULTS: The study population represented 97 055 weighted patient discharges with AKI. Analysis revealed AKI patients with Sjogren's compared with patients without Sjogren's had statistically significant lower hyperkalemia rates (adjusted odds ratio: 0.65, confidence interval: 0.46-0.92; P = .017. There was no statistically significant difference in mortality, LOS, hospital charges, and other outcomes. LIMITATIONS: Study is not up to date as data are from ICD-9 which are testing data from 2010 to 2013, and data were obtained through SJS codes, which have their limitations. Also, limitations included lack of data on metabolic acidosis, hypokalemia, and not including all causes of AKI. CONCLUSIONS: At present, our study is unique as it has examined prevalence, mortality, and outcomes of Sjogren's in patients with AKI. Patients with Sjogren's had significantly lower hyperkalemia during the hospitalization. Further research is needed to identify the underlying protective mechanisms associated with Sjogren's that resulted in lower hyperkalemia. TRIAL REGISTRATION: Not applicable.

CONTEXTE: La documentation portant sur les issues de l'insuffisance rénale aiguë (IRA) en présence du syndrome de Sjorden (SSJ) est assez peu abondante. L'IRA apparaît comme une cause importante de morbidité et de mortalité chez les patients atteints de maladies auto-immunes telles que le lupus érythémateux systémique. OBJECTIFS: Examiner les issues de l'IRA avec ou sans SSJ. Pour ce faire, nous avons consulté la période entre 2010 et 2013 de la base de données National Inpatient Sample (NIS) pour comparer la prévalence, la mortalité, les issues, la durée des hospitalisations, et les frais d'hospitalisation chez des patients atteints d'IRA avec ou sans SSJ. TYPE D'ÉTUDE: Une étude de cohorte rétrospective utilisant la NIS. CADRE: États-Unis. ÉCHANTILLON: Les congés pondérés de 97 055 patients atteints d'IRA tirés de la NIS. MESURES: Sans objet. MÉTHODOLOGIE: Les codes diagnostic CIM-9 ont servi à l'extraction des données de la NIS pour les adultes admis avec un diagnostic primaire d'IRA entre 2010 et 2013. La population étudiée a été divisée en deux groupes: avec ou sans syndrome de Sjorden. Des analyses par régression linéaire et multivariée ont été conduites pour corriger les covariables. Pour éviter les disparités, les patients atteints de sclérose systémique et de polyarthrite rhumatoïde ont été exclus de l'analyse puisque ces affections ne devaient pas constituer un résultat principal de l'étude. RÉSULTATS: La population étudiée était constituée de 97 055 patients atteints d'IRA et ayant obtenu leur congé de l'hôpital. L'analyse a révélé que les patients atteints d'IRA et du SSJ présentaient des taux d'hyperkaliémie statistiquement plus faibles (rapport de cotes [RC] corrigé: 0,65; IC à 95 %: 0,46-0,92; p =0,017) que les patients sans SSJ. Aucune différence significative n'a été observée entre les deux groupes en ce qui concerne la mortalité, la durée du séjour, les frais d'hospitalisation et les autres résultats. LIMITES: L'étude n'est pas à jour puisque les données sont tirées des codes CIM-9, soit sur des données de 2010 à 2013 obtenues par l'entremise des codes du SSJ, lesquels ont leurs propres limites. L'étude est également limitée par le manque de données sur l'acidose métabolique, l'hypokaliémie et par le fait qu'elle n'inclut pas toutes les causes d'IRA. CONCLUSION: À ce jour, notre étude est la seule qui ait examiné la prévalence, la mortalité et les issues du syndrome de Sjorgren chez les patients atteints d'IRA. Les patients atteints du syndrome de Sjogren ont présenté moins d'hyperkaliémie pendant leur hospitalisation. Des études supplémentaires sont nécessaires pour identifier les mécanismes sous-jacents, associés au syndrome de Sjogren, ayant entraîné moins d'hyperkaliémie. ENREGISTREMENT DE L'ESSAI: Sans objet.

Pneumococcal Meningitis Complicated by Spinal Cord Dysfunction and Acute Polyradiculopathy.

Background: Meningitis caused by Streptococcus pneumoniae is associated with devastating clinical outcomes. A considerable number of patients will develop long-term neurologic complications. Hearing loss, diffuse brain edema, and hydrocephalus are frequently encountered. Acute spinal cord dysfunction and polyradiculopathy can develop in some patients. Case Report: A 63-year-old female was admitted to our hospital with sudden-onset bilateral lower extremity weakness. On admission, the patient had evidence of spinal cord dysfunction given the abnormal motor and sensory physical examination findings and the absent sensation with a sensory level at dermatome T4 on neurologic examination. Computed tomography myelography did not show evidence of spinal cord compression or transverse myelitis. Cerebrospinal fluid examination was positive for pneumococcal meningitis. The patient was treated with antibiotics and steroids. Nerve conduction studies demonstrated the absence of response, suggesting damage to the peripheral nerves and polyradiculopathy. The patient was treated with plasmapheresis for possible Guillain-Barré syndrome; however, she did not improve despite appropriate antibiotics, steroids, and plasmapheresis. She developed persistent quadriparesis, sensory impairments in upper and lower extremities, and bowel and bladder sphincter dysfunction. Conclusion: Our case demonstrates the development of spinal cord dysfunction (supported by the sudden onset of paraplegia and the presence of a sensory level) and polyradiculopathy (flaccid paralysis, ascending weakness, and absence of response in neurophysiologic studies suggesting severe damage to the peripheral nerves). The appearance of either complication is unusual, and the simultaneous occurrence of both complications is even more uncommon.

Pulmonary Adenocarcinoma Presenting as a Pineal Gland Mass With Obstructive Hydrocephalus.

Background: Adenocarcinoma is the most prevalent type of non-small cell carcinoma of the lungs. Patients with lung adenocarcinoma often present with cough, dyspnea, pain, and weight loss. They can also present with signs and symptoms of brain metastasis because the lungs are one of the most common origins of metastatic brain cancer. We describe a rare case of adenocarcinoma of the lungs presenting with pineal region metastasis. Case Report: A 61-year-old male presented to the emergency department with dizzy spells and gait disturbance. Magnetic resonance imaging of the brain demonstrated a solitary mass in the pineal region with marked obstructive hydrocephalus. A stereotactic biopsy was performed, and metastatic adenocarcinoma consistent with pulmonary origin was diagnosed. Computed tomography scan of the chest revealed a spiculated mass. The patient died shortly after the diagnosis was made. Conclusion: The pineal region is an unusual site for brain metastasis. Although such metastasis has rarely been described, it should be considered in the differential diagnosis of pineal region tumors, especially for patients with suggestive clinical or histopathologic features of primary malignancy elsewhere.

The Impact of Hospital Teaching Status on Colonoscopy Perforation Risk: A National Inpatient Sample Study.

BACKGROUND: Colonoscopy has been widely used as a diagnostic tool for many conditions, including inflammatory bowel disease and colorectal cancer. Colonoscopy complications include perforation, hemorrhage, abdominal pain, as well as anesthesia risk. Although rare, perforation is the most dangerous complication that occurs in the immediate post-colonoscopy period with an estimated risk of less than 0.1%. Studies on colonoscopy perforation risk between teaching hospitals and non-teaching hospitals are scarce. METHODS: The National Inpatient Sample database was queried for patients who underwent inpatient colonoscopy between January 2010 and December 2014 in teaching versus non-teaching facilities in order to study their perforation rates. Our study population included 257,006 patients. Univariate regression was performed, and the positive results were analyzed using a multivariate regression module. RESULTS: Teaching hospitals had a higher risk of perforation (odds ratio 1.23, confidence interval 1.07 - 1.42, P = 0.004). Perforation rates were higher in females, patients with inflammatory bowel disease and dilatation of strictures. Polypectomy did not yield any statistical difference between the study groups. Other factors such as African-American ethnicity appeared to have a lower risk. CONCLUSION: Perforation rates are higher in teaching hospitals. More studies are needed to examine the difference and how to mitigate the risks.

A Unique Case of Severe Hematochezia: Ruptured Pseudoaneurysm of the Superior Rectal Artery.

Visceral artery aneurysms are rare, with an incidence of 0.01%-2% based on autopsy results. Among the visceral arteries, inferior mesenteric artery aneurysms are the rarest. To our knowledge, we report the first case of acute lower gastrointestinal bleeding in a 45-year-old man, arising from a nontraumatic pseudoaneurysm of the superior rectal artery, a branch of the inferior mesenteric artery. Urgent angiography provided the diagnosis and allowed successful hemostatic intervention via endovascular coil embolization. A subsequent routine colonoscopy revealed an ulcer with central yellow-bluish bulge in the distal rectum correlating with the site of the treated pseudoaneurysm.

Prosthetic Aortic Valve Endocarditis in a Patient With Birt-Hogg-Dube Syndrome due to Lactobacillus paracasei.

Various causative organisms and predisposing factors were implicated in the pathogenic process behind prosthetic valve endocarditis. Lactobacillus paracasei, a classic constituent of probiotics, rarely causes infections in humans and was reported only in few case reports. The use of probiotics was hypothesized to be a risk factor for these infections; however, no causative relationship could be drawn. We describe a 75-year-old woman with history of Birt-Hogg-Dube syndrome and bioprosthetic aortic valve replacement who presented with worsening dyspnea was found to have Lactobacillus paracasei bacteremia and evidence of bacterial vegetations noted on transesophageal echocardiography (TEE) along with evidence of severe aortic insufficiency. Based on antibiotics sensitivity profile, she was treated with penicillin and gentamycin, which resulted in bacterial clearance on repeat blood cultures, and the patient was transferred to a different facility to undergo replacement of the prosthetic aortic valve. Although Lactobacillus paracasei is rarely involved in human infections, it should be suspected in patients with underlying structural heart/valvular disease, recent antibiotic exposure or recent probiotic use who are presenting with evidence of infective endocarditis. Combination antibiotics including beta lactams, aminoglycosides and clindamycin are suggested treatment of choice for this organism.

Acute Retroviral Syndrome Presenting as Acute Hepatitis.

Acute retroviral syndrome (ARS) can present as a wide array of clinical manifestations. Establishing a diagnosis early in the disease course can provide an opportunity to minimize immunosuppression and limit further transmission of human immunodeficiency virus (HIV). We present a case of a previously healthy young male who presented with acute hepatitis, as a manifestation of ARS. Initial HIV antigen/antibody testing was negative; however, a high index of suspicion prompted HIV ribonucleic acid (RNA) virologic testing revealing >10 million RNA copies/mL. Anti-retroviral treatment was initiated, along with supportive measures, accomplishing resolution of the transaminitis and the restoration of CD4 counts within normal at one month. Early in the disease course, HIV screening immunoassay could still be negative; hence, confirmatory testing with HIV RNA virologic testing should be pursued when clinical suspicion is high. Prompt diagnosis and treatment can improve outcome and curtail viral transmission.