A man in his sixties with life-threatening febrile illness after travel abroad. / Ein mann i 60-åra med livstrugande febersjukdom etter utanlandsreise.

Background: African sleeping sickness is a neglected tropical disease seldom seen in European travellers. Case presentation: While working in Eastern Africa, a Norwegian man in his sixties developed weakness and fever. He was prescribed doxycycline after a negative malaria rapid test. On the third day of illness he returned to Norway and was admitted to the hospital upon arrival. On admission he was somnolent with fever, tachypnoea, tachycardia, jaundice, a hyperaemic rash, oliguria and haematuria. Blood tests revealed leukopenia, thrombocytopaenia, renal failure and liver dysfunction. Rapid tests were negative for malaria and dengue. Blood microscopy revealed high parasitaemia with trypanosomes indicating human African sleeping-sickness. He had been bitten by a tsetse fly 11 days prior in an area endemic for Trypanosoma brucei gambiense. However, the clinical picture was consistent with Trypanosoma brucei rhodesiense infection (East African sleeping sickness). Four days after starting treatment with suramin, spinal fluid examination revealed mild mononuclear pleocytosis but no visible parasites. Melarsoprol treatment for possible encephalitis was considered but suramin treatment was continued alone. He improved and remains healthy seven years later. PCR on blood was positive for T. b. rhodesiense. Interpretation: African sleeping sickness can also affect tourists to endemic areas. Onset can be acute, life-threatening and requires treatment with antiparasitic drugs not generally available in Norwegian hospitals.

Infective endocarditis: association between origin of causing bacteria and findings during oral infection screening.

BACKGROUND: Oral streptococci represent the causing microorganism for infective endocarditis (IE) in many patients. The impact of oral infections is questioned, and it has been suggested that bacteraemia due to daily routines may play a bigger part in the aetiology of IE. The aim of this study was to examine the association between oral health and infective endocarditis caused by oral bacteria in comparison with bacteria of other origin than the oral cavity. METHODS: A retrospective study was conducted at Haukeland University Hospital from 2006- 2015. All consecutive adult patients admitted to hospital for treatment of IE and subjected to an oral focus screening including orthopantomogram, were included. The clinical, radiological and laboratory characteristics of the patients, collected during oral infectious focus screening, were analysed. Patient survival was calculated using Kaplan-Meier and mortality rates were compared using Cox-regression. RESULTS: A total of 208 patients were included, 77% (n = 161) male patients and 23% (n = 47) female, mean age was 58 years. A total of 67 (32%) had IE caused by viridans streptococci. No statistically significant correlation could be found between signs of oral infection and IE caused by viridans streptococci. The overall mortality at 30 days was 4.3% (95% CI: 1.6-7.0). There was no statistical difference in mortality between IE caused by viridans streptococci or S. aureus (HRR = 1.16, 95% CI: 0.57-2.37, p = 0.680). CONCLUSION: The study indicates that the association between origin of the IE causing bacteria and findings during oral infection screening might be uncertain and may suggest that the benefit of screening and elimination of oral infections in patients admitted with IE might be overestimated. However, the results should be interpreted with caution and further studies are needed before any definite conclusions can be drawn.

Characteristics of 24-hour ambulatory blood pressure monitoring in a COVID-19 survivor.

COVID-19 infection primarily causes severe pneumonia complicated by acute respiratory distress syndrome and multiorgan failure requiring a ventilator support. We present a case of a 55-year-old male, admitted with COVID-19. He was obese but had no other medical conditions. His blood pressure was measured by his general physician on several occasions in the past, all values being normal (<140/90 mmHg). He developed multiorgan failure, requiring vasopressor and ventilator support for 17 days. A prone positioning improved the arterial oxygenation, and reduced the need for supplemental oxygen. After recovery, he showed persistently elevated blood pressure and sinus tachycardia both in clinic and out-of-clinic. The activation of the renin-angiotensin-aldosterone and sympathetic systems, volume-overload, hyperreninemia and cytokine storm might have contributed to the exaggerated cardiovascular response.

Eikenella exigua sp. nov., isolated from brain abscess and blood.

We herein describe the first novel species within the genus Eikenella since it was established in 1972 by the reclassification of 'Bacteroides corrodens' to Eikenella corrodens. From a polymicrobial brain abscess, we encountered an Eikenella isolate, PXXT, that could not validly be named E. corrodens. The isolate grew on blood agar with small, translucent, pitting colonies after 3 days of anaerobic incubation. By reviewing previously collected invasive isolates, we found an additional Eikenella strain, EI-02, from a blood culture exhibiting the same properties as PXXT. Phylogenetic analyses based on both whole genome and individual house-keeping genes confirmed that the two strains allocate in a phylogenetic cluster separate from E. corrodens. Using specific amplification and sequencing of the Eikenella nusG gene, we further detected the novel Eikenella species in six historic brain abscesses previously reported to contain E. corrodens based on 16S metagenomics. Out of 24 Eikenella whole-genome projects available in GenBank, eight cluster together with PXXT and EI-02. These isolates were recovered from brain abscess (n=2), blood (n=1), bone/soft tissue (n=3), parotid gland (n=1) and unknown (n=1). It remains to be investigated whether the new species can cause endocarditis. The average nucleotide identity value between strain PXXT and the E. corrodens type strain ATCC 23834T was 92.1 % and the corresponding genome-to-genome distance value was 47.1 %, both supporting the classification of PXXT as a novel species. For this species we propose the name Eikenella exigua. The type strain of E. exigua is PXXT (DSM 109756T, NCTC 14318T).

A travel-loving woman in her eighties with lower back pain and weight loss. / En reiseglad 80-åring med ryggsmerter og vekttap.

BACKGROUND: This case report presents one of the first documented incidents of chronic Q-fever (C. burnetii) in Norway. A comprehensive workup resulted in an unexpected finding. CASE PRESENTATION: A Norwegian woman in her eighties presented to a district general hospital with lower back pain, decreased general condition and weight loss. Computer tomography (CT) revealed a large thoracic aortic aneurysm presumed to be of mycotic origin, and later magnetic resonance imaging (MRI) scans revealed osteomyelitis in the surrounding vertebrae. Conventional diagnostic workup did not identify the causative agent. After more than 6 months of different examinations, surgery, exhausting invasive procedures and antimicrobial treatment, we were ultimately successful in determining the microbial cause of chronic mycotic aneurism and osteomyelitis to be C. Burnetii (Q-fever) through serological and PCR analysis. INTERPRETATION: An increasing proportion of the population in all age groups travel abroad, and clinicians should be aware of the increasing incidence of imported infectious diseases. Obtaining a thorough medical history is still an important tool in the diagnostic process.

Infective endocarditis in Western Norway: a 20-year retrospective survey.

BACKGROUND: To investigate epidemiological trends of infective endocarditis (IE) in western Norway a retrospective study was performed. METHODS: Characteristics of 706 IE admissions from 1996 to 2005 and 2006 to 2015 were analysed and compared using the Chi-square test for categorical variables and the t-test for age. Survival was analysed by multiple Cox regression and reported by the hazard ratio (HR). RESULTS: Mean annual incidence rates increased from 4.6 to 7.4 per 100,000 inhabitants (rate ratio: 1.97, 95% confidence interval: 1.52-2.56, p < .001). Non-viridans streptococci, enterococci and Staphylococcus aureus (S. aureus), were all independently associated with increased mortality. The frequency of IE caused by enterococci increased from 3.7 to 13.0% (p < .001). The proportion of intravenous drug users (IVDU) increased from 16.5 to 23.5% (p = .015) and had increasing aortic valve involvement (p = .023). Prosthetic valve endocarditis (PVE) constituted 30% of IE cases in both decades with biological PVE increasing from 9.4 to 22.1% (p < .001) and mechanical PVE decreasing from 18.7 to 8.9% (p < .001). In the last decade, valve replacement surgery was performed in 37.6% of the patients, of which 85.5% received a bioprosthesis. CONCLUSIONS: The incidence of IE increased significantly. Non-viridans streptococci, enterococci and S. aureus were all significantly associated with increased mortality. The increased number of enterococcal IE and the increased number of IVDUs with left-sided IE constituted new challenges. Biological implants were preferred in a majority of patients requiring surgery.

Clinical and molecular characteristics of infective ß-hemolytic streptococcal endocarditis.

Streptococcus pyogenes (S. pyogenes) and Streptococcus dysgalactiae subspecies equisimilis (SDSE) cause considerable morbidity and mortality, and show similarities in disease manifestations and pathogenic mechanisms. Their involvement in infective endocarditis, however, has not been well described. Invasive S. pyogenes and SDSE infections in Health Region Bergen, Norway, in the period 1999-2013 were reviewed, and sixteen cases of endocarditis were identified. The median duration of symptoms was 2.5days, the frequency of embolic events 50%, 38% received valve replacement and the 30-day mortality was 25%. In S. pyogenes, a significant correlation was observed between the repertoire of fibronectin-binding genes, phenotypic binding ability to fibronectin and disease manifestations. Conversely, no associations between phenotypic and genotypic characteristics were detected in SDSE. S. pyogenes and SDSE endocarditis is characterized by rapid and severe clinical manifestations. The pathogenesis is multifactorial, but our results infer a potential role of fibronectin binding in the development of S. pyogenes endocarditis.

Cardiac surgery for infective endocarditis in patients with intravenous drug use.

OBJECTIVES: Intravenous drug users have a high risk of infective endocarditis and reduced survival. Cardiac surgery may be recommended for these patients, but redo surgery is controversial. This study describes the characteristics and outcomes of intravenous drug users accepted for surgery during a 12-year period. METHODS: This retrospective study included 29 injecting drug users treated with valve surgery for endocarditis between January 2001 and December 2013 at a tertiary academic centre. Survival was assessed by Kaplan-Meier analysis. RESULTS: The median patient age was 36 (24-63) years and 27 patients (93%) were male. Staphylococcus aureus (52%) and Enterococcus faecalis (17%) were the most common microorganisms. Common illicit drugs were opioids (69%), amphetamines (52%) and benzodiazepines (24%). Mixed abuse was reported in 66% of patients. Seven patients (24%) had prior intracardial implants or native valve pathology. Twenty-five patients (86%) were positive for hepatitis C virus antibody, but none carried the human immunodeficiency virus. Twelve (41%) were homeless and 15 (52%) had poor dental hygiene. Three patients (10%) received medication-assisted rehabilitation before surgery. The main indications for surgery were regurgitation and secondary heart failure (86%), embolization (41%) and uncontrolled infection (24%). Aortic valve replacement was performed in 24 patients (83%), either as part of univalvular or multiple valve surgery. Seven patients (24%) had multivalvular endocarditis. All but 3 patients received biological valve prostheses. The 30-day mortality was 7% after first time surgery. During follow-up, 15 patients (52%) presented with reinfection: 10 (35%) were offered a second and 2 (7%) a third operation. Thirty-day mortality was 10% after redo surgery. Thirteen patients (45%) died within a median of 22 (0-84) months. Continued intravenous drug use was reported in 70 and 44% of patients after the first and second operation, respectively. CONCLUSIONS: Cardiac surgery for infective endocarditis has acceptable early postoperative results among intravenous drug users. The 2- and 5-year survival were 79 and 59%, respectively. The number of reinfections was high within 2 years, as continued drug use seems to be a major challenge for this group.

New tricks from an old cow: infective endocarditis caused by Streptococcus dysgalactiae subsp. dysgalactiae.

We present a case of infective endocarditis caused by Streptococcus dysgalactiae subsp. dysgalactiae, a major cause of bovine mastitis and previously thought to be an animal-restricted pathogen. The patient reported no direct contact with animals, and the clinical course was severe and complicated.