'The Year of Living Dangerously': Successful Rhodococcus Equi Therapy in an Immunosuppressed Patient with Minimal Toxicity by One Year of Continuous Intravenous Vancomycin Therapy Combined with Oral Levofloxacin And Rifampicin.

Background: Rhodococcus equi is a Gram-positive microorganism that causes infections, particularly in immunocompromised patients. Treatment duration can be prolonged. While vancomycin is an effective drug in this scenario, its use may lead to renal damage. Studies have shown that continuous vancomycin infusion appears to be a safe strategy in terms of adverse effects compared to bolus administration. Case description: We present the case of a 71-year-old female liver transplant recipient. After being diagnosed with a mediastinal infection caused by Rhodococcus equi with poor response to initial therapy, she required 12 months of continuous intravenous domiciliary infusion of vancomycin combined with oral levofloxacin and rifampicin. There was no drug-related complication throughout the follow-up. Conclusions: The use of continuous vancomycin infusion has emerged as a safer, more efficient, and cost-effective alternative to intermittent administration. We want to emphasise the uniqueness of this case, where despite the unprecedented treatment duration, no adverse effects occurred. LEARNING POINTS: Vancomycin therapy based on continuous infusion represents a safer and cheaper strategy than classic intermittent administration.The use of continuous infusion facilitates the management of complex infections with outpatient antimicrobial therapy.

Persistir y no desistir: diagnosticando un caso de porfiria aguda intermitente / Persist and do not give up: diagnosing a case of acute intermittent porphyria

A young woman with a history of asthma and anxiety-depressive syndrome, with poor adherence to treatment in long follow-up by Psychiatry and Family Medicine. She consulted for persistent abdominal pain refractory to conventional analgesia, associated with hypertension, hyponatremia, and progressive muscle weakness. It was performed a first Hoesch test which was positive; however, the study of porphyrins in blood and urine was inconclusive. On the other hand, she presented an acute respiratory failure requiring transfer to the ICU. A second Hoesch test was repeated, remaining positive, in addition to the presence of an increase in porphobilinogen in 24-hour urine and delta-aminolevulinic acid. Genetic study was performed, being compatible with acute intermittent porphyria. Treatment with carbohydrates and hemin was started with an adequate response. Approval of givosiran (RNA interference drug) has been requested. The patient has shown clinical improvement. Due to functional deterioration, she required rehabilitation support. (AU)

Mujer joven con antecedentes de asma y síndrome ansioso-depresivo con escasa adherencia al tratamiento, en seguimiento por Psiquiatría y Médico de Familia desde hace años. Consultó por dolor abdominal persistente y refractario a analgesia convencional, junto con hipertensión, hiponatremia y debilidad muscular progresiva. Se realizó un primer test de Hoesch que fue positivo, aunque el estudio inicial de porfirinas en sangre y orina no fue concluyente. Posteriormente presentó insuficiencia respiratoria aguda, precisando traslado a UCI. Se repitió el test de Hoesch, nuevamente positivo, además de hallar incremento de porfobilinógeno en orina de 24 horas y de ácido delta-aminolevulínico. El estudio genético fue compatible con porfiria aguda intermitente. Recibió tratamiento con carbohidratos y hemina con adecuada respuesta. Está pendiente de aprobación de givosiran (fármaco ARN de interferencia). Ha evolucionado favorablemente, precisando soporte rehabilitador por marcado deterioro funcional. (AU)

Longitudinal relationship of liver injury with inflammation biomarkers in COVID-19 hospitalized patients using a joint modeling approach.

The mechanisms underlying liver disease in patients with COVID-19 are not entirely known. The aim is to investigate, by means of novel statistical techniques, the changes over time in the relationship between inflammation markers and liver damage markers in relation to survival in COVID-19. The study included 221 consecutive patients admitted to the hospital during the first COVID-19 wave in Spain. Generalized additive mixed models were used to investigate the influence of time and inflammation markers on liver damage markers in relation to survival. Joint modeling regression was used to evaluate the temporal correlations between inflammation markers (serum C-reactive protein [CRP], interleukin-6, plasma D-dimer, and blood lymphocyte count) and liver damage markers, after adjusting for age, sex, and therapy. The patients who died showed a significant elevation in serum aspartate transaminase (AST) and alkaline phosphatase levels over time. Conversely, a decrease in serum AST levels was observed in the survivors, who showed a negative correlation between inflammation markers and liver damage markers (CRP with serum AST, alanine transaminase [ALT], and gamma-glutamyl transferase [GGT]; and D-dimer with AST and ALT) after a week of hospitalization. Conversely, most correlations were positive in the patients who died, except lymphocyte count, which was negatively correlated with AST, GGT, and alkaline phosphatase. These correlations were attenuated with age. The patients who died during COVID-19 infection displayed a significant elevation of liver damage markers, which is correlated with inflammation markers over time. These results are consistent with the role of systemic inflammation in liver damage during COVID-19.

An Atypical Manifestation of Mycobacterium tuberculosis Infection.

INTRODUCTION: Aortitis is seen in a wide variety of diseases. It was rarely found in the past but this is changing because of new imaging techniques. CASE DESCRIPTION: We present the case of a 45-year-old man who was found on thyroid ultrasound to have infrarenal aortitis and pathological lymphadenopathies in different locations. After an exhaustive diagnostic process, tuberculous aortitis, an infrequent manifestation of extrapulmonary tuberculosis, was diagnosed. The condition resolved after a 6-month course of antibiotics and a 6-week course of corticosteroids. CONCLUSION: Tuberculous aortitis is an atypical manifestation of Mycobacterium tuberculosis infection. The absence of typical symptoms and the difficulty of isolating the microorganism makes its diagnosis difficult. Therefore, clinical suspicion, microbiological tests and imaging are key for reaching the diagnosis and starting treatment for a serious disease that can cause aortic aneurysm and dissection. LEARNING POINTS: New imaging techniques can identify aortitis for the diagnosis of extrapulmonary Mycobacterium tuberculosis infection.The extrapulmonary manifestations of Mycobacterium tuberculosis infection are diverse and include aortitis.Prompt and accurate differentiation between infectious and non-infectious causes of aortitis determines which of two very different therapeutic paths should be followed and hence the prognosis of the patient.

Analysis of predisposing factors for the development of Clostridioides difficile infection recurrence.

AbstractThe purpose of this study is to evaluate the influence of several risk factors and, among them, the role of different types of antibiotics, in the development of the first recurrent episode of Clostridioides difficile (CD) infection. We performed a case control study from 2006 to 2016. We included patients admitted to the hospital with CD infection that received any antibiotic treatment during the year before the onset of the infection. First, we described the characteristics of CD infection in a Spanish third level hospital and then we compared first cases of CD infection that presented recurrence with those that did not. We included 110 cases, corresponding to 94 individuals. There were 14 first CD infection episodes that later presented recurrence (12.7%). Receiving more than 3 types of antibiotics during the year before the onset of symptoms was associated with higher risk of presenting a recurrent episode (OR = 4.69, 95% CI 1.01-21.78), as well as the past history of neoplasia (OR = 4.58, 95% CI 1.00-20.98). The number of previous hospital admissions was associated with the development of recurrences in the univariate study (p < 0.05). No differences were observed related to the type of antibiotic used immediately before the CD episode neither with the treatment received. The number of types of antibiotics used during the year before the first episode of CD infection or having a personal history of neoplasia was associated with 4 times higher risk of recurrent episodes. Type of antibiotic used did not show to influence recurrences.