Outbreak report of polymyxin-carbapenem-resistant Klebsiella pneumoniae causing untreatable infections evidenced by synergy tests and bacterial genomes.

Polymyxin-carbapenem-resistant Klebsiella pneumoniae (PCR-Kp) with pan (PDR)- or extensively drug-resistant phenotypes has been increasingly described worldwide. Here, we report a PCR-Kp outbreak causing untreatable infections descriptively correlated with bacterial genomes. Hospital-wide surveillance of PCR-Kp was initiated in December-2014, after the first detection of a K. pneumoniae phenotype initially classified as PDR, recovered from close spatiotemporal cases of a sentinel hospital in Rio de Janeiro. Whole-genome sequencing of clinical PCR-Kp was performed to investigate similarities and dissimilarities in phylogeny, resistance and virulence genes, plasmid structures and genetic polymorphisms. A target phenotypic profile was detected in 10% (12/117) of the tested K. pneumoniae complex bacteria recovered from patients (8.5%, 8/94) who had epidemiological links and were involved in intractable infections and death, with combined therapeutic drugs failing to meet synergy. Two resistant bacterial clades belong to the same transmission cluster (ST437) or might have different sources (ST11). The severity of infection was likely related to patients' comorbidities, lack of antimicrobial therapy and predicted bacterial genes related to high resistance, survival, and proliferation. This report contributes to the actual knowledge about the natural history of PCR-Kp infection, while reporting from a time when there were no licensed drugs in the world to treat some of these infections. More studies comparing clinical findings with bacterial genetic markers during clonal spread are needed.

Persistent elevation of carcinoembryonic antigen as first presentation of a medullary thyroid carcinoma.

Carcinoembryonic antigen (CEA) is still the most widely used tumour marker for gastrointestinal cancer. CEA was originally thought to be a specific marker for colorectal cancer, but it turned out to be a non-specific marker for further studies. CEA levels can be elevated in breast, lung and liver cancers, among others, including medullary thyroid cancer. The authors report a case of a 73-year-old woman who had a right hemicolectomy for an ascending colon adenocarcinoma and showed a persistent elevation in the CEA marker during follow-up. After several imaging tests, recurrence of the colon cancer was not found, but the presence of thyroid nodules had been detected. The diagnosis of a medullary thyroid carcinoma was made after the finding of a high value of calcitonin. The patient had a total thyroidectomy with resection of the central and lateral lymph nodes.

Resistência bacteriana aos antibióticos: o que você deve saber e como se prevenir

Cartilha elaborada por Caio Augusto Martins Aires, Marise Dutra Asensi com os colaboradores Natália Maria Lanzarini, Bruno Gouveia Motta, Polyana Silva Pereira, pesquisadores do Instituto Oswaldo Cruz (IOC/Fiocruz). A resistência aos antibióticos é considerada uma das maiores ameaças à saúde global atualmente? O surgimento de 'superbactérias', microrganismos resistentes à maioria dos fármacos disponíveis para tratamento, é um fenômeno associado ao uso indiscriminado desses medicamentos. A resistência é proveniente de modificações na estrutura de bactérias que podem ocorrer de forma aleatória, devido a alterações no material genético do microrganismo, ou por meio da aquisição de material genético de fontes externas, como vírus, outras bactérias e do ambiente. O uso indiscriminado dos antibióticos por instituições de saúde, pela população e em práticas agropecuárias também é um fator que contribui para o aumento da resistência. Entre as formas de prevenção, a cartilha recomenda, acima de tudo, o uso consciente de antibióticos, com utilização apenas no tratamento de infecções bacterianas e de acordo com prescrição médica. Além disso, a higienização adequada das mãos e cuidados específicos durante visitas a pacientes internados em hospitais podem prevenir a transmissão dos microrganismos.

Splenic Artery Pseudoaneurysm.

Splenic artery pseudoaneurysm is an extremely rare entity, although it is the most frequent location of visceral pseudoaneurysms. Trauma or previous pancreatitis (where the proteolytic pancreatic enzymes lead to the formation of pseudoaneurysm, as a result of enzymatic injury to the splenic artery wall) (Amico and Alves in Pancreatology 14: 144-145, 2014) is the most frequent causes. A high degree of suspicion is required for the accurate diagnosis. The authors present a case of splenic artery pseudoaneurysm in a middle-aged man who came to the emergency department with several days of abdominal pain.

Left Paraduodenal Hernia.

Left paraduodenal hernia is an entrapment of the small bowel into the Landzert fossa, an unusual congenital peritoneal defect behind the descending mesocolon that results from failure of part of the descending mesocolon to fuse with the posterior parietal peritoneum (Doishita et al. in Radiographics, 36(1): 88-106, 2016). This fossa is reported to be present in approximately 2% of autopsy bodies. The authors present a case of a left paraduodenal hernia in a young woman.

Bronchoesophageal Fistula in the Setting of Tuberculosis Infection.

Acquired bronchoesophageal fistula can have their origin in a benign or malign cause. Benign bronchoesophageal fistula is rare and often associated with nonspecific symptoms that may delay the correct diagnosis. The authors present a case of a bronchoesophageal fistula in a 57-year-old woman caused by tuberculosis infection.

Fasciola hepatica-a "Diver" in the Biliary Tree.

Fasciola hepatica is an endemic trematode that affects millions of people worldwide. The human being can be an accidental host through consumption of contaminated food or water. The authors present a case of hepatic fascioliasis in a 69-year-old Portuguese woman who recently traveled from Egypt, Brazil, and India.