An unusual case of heart failure due to ANCA-negative vasculitis: A case report and focused review of the literature.

Key Clinical Message: Heart failure due to ANCA-negative vasculitis, is a rare potentially life-threatening manifestation of ANCA vasculitis. Therefore, physicians must always pay attention to this manifestation for proper disease diagnosis and treatment. Abstract: Less than 10% of primary vasculitides cause cardiac dysfunction, with Takayasu's arteritis, polyarteritis nodosa, and eosinophilic granulomatosis with polyangiitis being the most common cases. However, any cardiac tissue can be affected by ANCA vasculitis. We present a case of heart failure with reduced ventricular ejection fraction due to ANCA negative-vasculitis.

Anti-GM-CSF Neutralizing Autoantibodies in Colombian Patients with Disseminated Cryptococcosis.

BACKGROUND: Cryptococcosis is a potentially life-threatening fungal disease caused by encapsulated yeasts of the genus Cryptococcus, mostly C. neoformans or C. gattii. Cryptococcal meningitis is the most frequent clinical manifestation in humans. Neutralizing autoantibodies (auto-Abs) against granulocyte-macrophage colony-stimulating factor (GM-CSF) have recently been discovered in otherwise healthy adult patients with cryptococcal meningitis, mostly caused by C. gattii. We hypothesized that three Colombian patients with cryptococcal meningitis caused by C. neoformans in two of them would carry high plasma levels of neutralizing auto-Abs against GM-CSF. METHODS: We reviewed medical and laboratory records, performed immunological evaluations, and tested for anti-cytokine auto-Abs three previously healthy HIV-negative adults with disseminated cryptococcosis. RESULTS: Peripheral blood leukocyte subset levels and serum immunoglobulin concentrations were within the normal ranges. We detected high levels of neutralizing auto-Abs against GM-CSF in the plasma of all three patients. CONCLUSIONS: We report three Colombian patients with disseminated cryptococcosis associated with neutralizing auto-Abs against GM-CSF. Further studies should evaluate the genetic contribution to anti-GM-CSF autoantibody production and the role of the GM-CSF signaling pathway in the immune response to Cryptococcus spp.

Trombosis séptica portal secundaria a diverticulitis / Portal septic thrombophlebitis secondary to diverticulitis

Resumen La trombosis séptica de la vena porta es una complicación infrecuente de la diverticulitis, la apendicitis y de otras infecciones intraabdominales. Se asocia a elevadas tasas de complicaciones, como isquemia mesentérica, absceso hepático, hipertensión portal o muerte. Se presenta el caso de un paciente de 67 años quien consultó por fiebre, dolor abdominal e ictericia, y en quien se documentó bacteriemia por Escherichia coli y Streptococcus dysgalactiae. En las imágenes se identificó trombosis de la porta hepática secundaria a enfermedad diverticular aguda, lo que configura un diagnóstico de pileflebitis séptica. El paciente recibió terapia antibiótica dirigida, sin anticoagulación, obteniéndose adecuada respuesta clínica. Se realiza una discusión sobre el diagnóstico, etiología y tratamiento de la trombosis séptica portal.

Abstract Septic thrombosis of the portal vein is a rare complication of diverticulitis, appendicitis and other intra-abdominal infections; it is associated with high rates of complications, such as mesenteric ischemia, liver abscess, portal hypertension or death. We present the case of a 67-year-old patient who consulted for fever, abdominal pain and jaundice, and in whom Escherichia coli and Streptococcus dysgalactiae bacteremia was documented; images showed hepatic portal thrombosis secondary to acute diverticular disease, which configures a diagnosis of septic pylephlebitis. The patient received targeted antibiotic therapy without anticoagulation, with adequate clinical response. The diagnosis, etiology, and treatment of portal septic thrombosis are discussed.

Alta sensibilidad a la mupirocina en aislados de Staphylococcus aureus que colonizan pacientes en hemodiálisis en una unidad renal de Medellín, Colombia / High mupirocin susceptibility in isolates of Staphylococcus aureus colonizing hemodialysis patients in a dialysis unit at Medellín

RESUMEN Objetivo: describir el porcentaje de resistencia a la mupirocina y a otros antibióticos en aislados de Staphylococcus aureus que colonizan pacientes en hemodiálisis. Métodos: estudio descriptivo en el que se incluyeron pacientes en hemodiálisis en una unidad renal de Medellín. La colonización por S. aureus fue evaluada en las fosas nasales y en la piel. La identificación bacteriana se realizó por PCR y la sensibilidad antibiótica se determinó por el sistema automatizado VITEK-2 y por el método E-test. Las características clínicas de los pacientes fueron evaluadas con la historia clínica. Resultados: se incluyeron 210 pacientes, de estos el 50,5 % (n = 106) fueron mujeres, con una mediana para la edad de 62 años (RIC 51,87-71,13). De las características clínicas se destacó el uso frecuente de antibióticos: 59 % (n = 124) y la historia de hospitalización: 69 % (n = 145). El porcentaje de colonización por S. aureus fue de 33,8 % (n = 71) y el sitio más frecuente de colonización fue las fosas nasales (19 %; n = 40). Todos los aislados fueron sensibles a la mupirocina por el método de VITEK-2. Sin embargo, un aislado presentó resistencia de bajo nivel a la mupirocina por E-test. La colonización por aislados resistentes a meticilina (SARM) fue de 4,8 % (n = 10) y estos presentaron, principalmente, resistencia solamente a la oxacilina (58,3 %; n = 7). Conclusión: la alta sensibilidad a la mupirocina en aislados de S. aureus colonizantes sugiere su uso como terapia profiláctica en pacientes en hemodiálisis con alto riesgo de infección. Es importante fortalecer los programas de uso racional de antibióticos para evitar la diseminación de mecanismos de resistencia a estos y a otros en las unidades renales.

SUMMARY Objective: To describe the resistance percentage to mupirocin and other antibiotics in Staphylococcus aureus isolates colonizing hemodialysis patients. Methods: A descriptive study was conducted at an outpatient dialysis center in Medellín and hemodialysis patients with catheter were included. Colonization by S. aureus was evaluated in nostrils and skin. Bacterial identification was performed by PCR and antibiotic susceptibility was determined by the Vitek-2 automated system and by E-test. Clinical information was obtained from medical records. Results: Two hundred and ten patients were included, of which 50.5% (n=106) were women, with a median for the age of 62 years (IQR 51,87-71,13). Among the clinical characteristics, the frequent use of antibiotics 59% (n=124) and the history of hospitalization 69% (n=145) were highlighted. The percentage of colonization by S. aureus was 33.8% (n=71) and the most frequent site of colonization was nostrils (19%; n=40). All isolates were susceptible to mupirocin by the method of Vitek-2. However, one isolate showed low level resistance to mupirocin by E-test. Colonization by methicillinresistant isolates (MRSA) was 4.8% (n=10); which presented mainly resistance only to oxacillin (58,3%; n = 7). Conclusion: The high susceptibility to mupirocin in isolates of colonizing S. aureus suggests its use as prophylactic therapy in hemodialysis patients with high risk of infection. It is important to strengthen programs for the rational use of antibiotics to prevent the spread of mechanisms of resistance to this and other antibiotics at dialysis units.

Knowledge, attitude, and practice regarding antibiotic use and resistance among medical students in Colombia: a cross-sectional descriptive study.

BACKGROUND: This study was designed to describe the knowledge, attitude, and practice regarding antibiotic use and resistance among medical students in Medellín, Colombia. METHODS: A cross-sectional study was conducted among medical students from three universities from September to December 2018. The sample size was calculated, the classrooms were visited, and those students who were willing to participate were invited to do so. The data collection instrument was constructed in three stages: i) the literature was systematically reviewed, ii) the items from the studies identified were extracted, and iii) item reduction was performed with exploratory factor analysis. Data were analyzed by calculating absolute and relative frequencies and means for quantitative variables. The indexes of knowledge, attitude, and practice were transformed to a scale from 0 (worst possible score) to 100. Comparisons were performed using the Mann-Whitney U test, Kruskall-Wallis H test, and linear regressions. RESULTS: Five hundred and thirty-two medical students were included with a response rate of 96%. Of the total participants, 49.1% reported having used antibiotics within the past year. Regarding knowledge, only 18.2% had heard of the term "antimicrobial stewardship" and 69.3% were aware that empiric antibiotic therapy contributes to antibiotic resistance. Regarding attitude, 11.6% considered that antibiotics should be discontinued as soon as symptoms disappear and 24.6% stated that it is better to prescribe broad-spectrum antibiotics to ensure that the patient is cured. Regarding practice, 28.5% recognized that resistance is a multifactorial problem, but they do not act on it because they consider that individual actions would have little impact. The adjusted linear regression showed that the variables associated with knowledge, attitude, and practice were socioeconomic status, training cycle, university, previous experience of research or education, the general perception of the training received, and antibiotic consumption. CONCLUSION: Knowledge, attitude, and practice differ widely depending on the university, training cycle, and socioeconomic status, and a significant proportion of students consider that the standard of training received at the university on antibiotics and bacterial resistance is poor or mediocre. These findings show that there is a need to strengthen the medical students' curriculum on antibiotics, mechanisms of antibiotic resistance, and the prudent use of antibiotics as an important strategy to combat problem-resistant public health, primarily in endemic countries.

Knowledge regarding antibiotic use among students of three medical schools in Medellin, Colombia: a cross-sectional study.

BACKGROUND: The objective of the present study was to describe the knowledge regarding the antibiotic therapy of students of three medical schools in Medellín, Colombia. METHODS: The study population comprised medical students who were enrolled in three universities. The instrument contained questions regarding their current academic term, the university, the perceived quality of the education received on antibiotic therapy and bacterial resistance, and specific questions on upper respiratory tract infections, pneumonia, urinary tract infections, and skin and soft tissue infections. The information was analyzed by calculating frequencies and measures of dispersion and central tendency. Knowledge regarding the treatment for each type of infection was compared using the Mann-Whitney U test and the Kruskal-Wallis H test. RESULTS: We included 536 medical students, of which 43.5% students consider that the university has not sufficiently trained them to interpret antibiograms and 29.6% students consider that the quality of information received on the subject at their university ranges from regular to poor. The mean score for knowledge regarding antibiotic therapy for upper respiratory tract infections was 44.2 (9.9) on a scale from 0 to 100. The median score with regard to the treatment of pneumonia was 52.9 (14.7), that of urinary tract infection was 58.7 (14.8), and that of skin and soft tissue infections was 63.1 (19.4). The knowledge regarding antibiotic therapy for upper respiratory tract infections, pneumonia, and urinary tract infection does not improve with the academic term, the university, or perceived quality of the education received. CONCLUSION: A large proportion of medical students perceive that the training received from the university is insufficient with regard to antibiotic use and bacterial resistance, which is consistent with the limited knowledge reflected in the selection of antibiotic treatment for respiratory, urinary tract, and skin and soft tissue infections. Overall, the situation was identical among all universities, and it did not significantly increase with the completion of an academic term.

Risk factors and survival of patients infected with carbapenem-resistant Klebsiella pneumoniae in a KPC endemic setting: a case-control and cohort study.

BACKGROUND: Many gaps in the burden of resistant pathogens exist in endemic areas of low- and middle-income economies, especially those endemic for carbapenem resistance. The aim of this study is to evaluate risk factors for carbapenem-resistance, to estimate the association between carbapenem-resistance and all-cause 30-day mortality and to examine whether mortality is mediated by inappropriate therapy. METHODS: A case-control and a cohort study were conducted in one tertiary-care hospital in Medellín, Colombia from 2014 to 2015. Phenotypic and genotypic characterization of isolates was performed. In the case-control study, cases were defined as patients infected with carbapenem-resistant K. pneumoniae (CRKP) and controls as patients infected with carbapenem-susceptible K. pneumoniae (CSKP). A risk factor analysis was conducted using logistic regression models. In the cohort study, the exposed group was defined as patients infected with CRKP and the non-exposed group as patients infected with CSKP. A survival analysis using an accelerated failure time model with a lognormal distribution was performed to estimate the association between carbapenem resistance and all-cause 30-day-mortality and to examine whether mortality is mediated by inappropriate therapy. RESULTS: A total of 338 patients were enrolled; 49 were infected with CRKP and 289 with CSKP. Among CRKP isolates CG258 (n = 29), ST25 (n = 5) and ST307 (n = 4) were detected. Of importance, every day of meropenem (OR 1.18, 95%CI 1.10-1.28) and cefepime (OR 1.22, 95%CI 1.03-1.49) use increase the risk of carbapenem resistance. Additional risk factors were previous use of ciprofloxacin (OR 2.37, 95%CI 1.00-5.35) and urinary catheter (OR 2.60, 95%CI 1.25-5.37). Furthermore, a significant lower survival time was estimated for patients infected with CRKP compared to CSKP (Relative Times 0.44, 95%CI 0.24-0.82). The strength of association was reduced when appropriate therapy was included in the model (RT = 0.81 95%CI 0.48-1.37). CONCLUSION: Short antibiotic courses had the potential to reduce the selection and transmission of CRKP. A high burden in mortality occurred in patients infected with CRKP in a KPC endemic setting and CRKP leads to increased mortality via inappropriate antibiotic treatment. Furthermore, dissemination of recognized hypervirulent clones could add to the list of challenges for antibiotic resistance control.

Secuestro pulmonar en adultos: reporte de tres casos y revisión de la literatura / Adult bronchopulmonary sequestration: report of three cases and review of the literature

Resumen El secuestro pulmonar es una enfermedad congénita infrecuente caracterizada por la presencia de una porción de parénquima pulmonar que recibe vascularización independiente de la circulación sistémica. Se presentan tres casos de secuestro pulmonar intralobares, de presentación tardía, uno de ellos asociado a una malformación adenomatosa quística y en los cuales el manejo se completó por videotoracoscopia: dos de ellos con lobectomía total y uno con lobectomía sublobar. Se trata de una enfermedad de presentación clínica variable y cuyo tratamiento es, en la mayoría de los casos, quirúrgico, requiriéndose usualmente resecciones lobares, las cuales pueden llevarse a cabo de manera eficaz y segura por videotoracoscopia.

Abstract Pulmonary sequestration is an infrequent congenital disease characterized by the presence of a portion of pulmonary parenchyma that receives vascularization independent of the systemic circulation. We present three cases of intralobar pulmonary sequestration of late presentation, one of them associated with a cystic adenomatous malformation and in which the management was completed by videothoracoscopy: two of them with total lobectomy and the other with sublobar lobectomy. It is a disease of variable clinical presentation and whose treatment is, in most cases, surgical, usually requiring lobar resections, which can be carried out effectively and safely by video-assisted thoracoscopy.

Disseminated toxoplasmosis in a heart transplant patient despite co-trimoxazole prophylaxis: A case report.

We report the case of a 61 year-old male who underwent heart transplantation eight months before developing a systemic condition with central nervous system, lung, kidney, colonic, cutaneous, and hematologic involvement, found to be secondary to a systemic toxoplasmosis despite co-trimoxazole prophylaxis in a previous-to-transplant seronegative patient receiving a heart from a seropositive donor. A review of prophylactic options in our environment is discussed.

Toxoplasmosis diseminada en un paciente con trasplante de corazón a pesar de la profilaxis con trimetoprim-sulfametoxazol / Disseminated toxoplasmosis in a heart transplant patient despite cotrimoxazole prophylaxis: A case report

Resumen Se reporta el caso de un paciente de sexo masculino, de 61 años de edad, quien ocho meses después de someterse a un trasplante de corazón presentó una enfermedad sistémica con compromiso del sistema nervioso central y del sistema inmunológico, así como de pulmón, riñón, colon y piel, y a quien finalmente se le diagnosticó toxoplasmosis diseminada, a pesar de haber recibido profilaxis con trimetoprim-sulfametoxazol, debido a que el órgano provenía de un donante positivo para toxoplasmosis siendo él un receptor negativo. Se discuten las opciones de profilaxis en nuestro medio.

Abstract We report the case of a 61 year-old male who underwent heart transplantation eight months before developing a systemic condition with central nervous system, lung, kidney, colonic, cutaneous, and hematologic involvement, found to be secondary to a systemic toxoplasmosis despite co-trimoxazole prophylaxis in a previous-to-transplant seronegative patient receiving a heart from a seropositive donor. A review of prophylactic options in our environment is discussed.

Acinetobacter baumannii: importancia clínica, mecanismos de resistencia y diagnóstico / Acinetobacter baumannii: Clinical importance, resistance mechanisms and diagnosis

Acinetobacter baumannii ha emergido como una bacteria de gran importancia clínica. Esta bacteria ha sido relacionada con altos porcentajes de mortalidad y posee una alta capacidad para diseminarse en el ambiente hospitalario. Con el paso del tiempo, Acinetobacter baumannii ha adquirido diferentes mecanismos de resistencia a los antibióticos y en la actualidad se reporta resistencia a carbapenémicos, aminoglicósidos, quinolonas y polimixinas, lo que ha complicado el manejo de las infecciones ocasionadas por esta bacteria. El problema se agrava aún más con las limitaciones en el diagnóstico y la carencia de métodos fenotípicos estandarizados que permitan detectar los mecanismos de resistencia específicos. En Colombia se han descrito altos porcentajes de resistencia a los carbapenémicos, lo que ha limitado las opciones terapéuticas y hace necesario el conocimiento de la epidemiología local para establecer medidas de control más certeras.

Currently Acinetobacter baumannii has become in a microorganisms of great clinical importance. It has an extraordinary capacity to spread in the hospital environment and it has been associated with high mortality rates. Acinetobacter baumannii has acquired different resistance mechanisms to antibiotics with reports resistance to carbapenems, aminoglycosides, quinolones and polymyxins; which has complicated the therapy of the infections caused for this pathogen. The problem is further due to the limitations in the diagnosis and the lack of standardized phenotypic methods to detect specific resistance mechanisms. In Colombia has reported high percentages of resistance to carbapenems, which has reduced therapeutic options. The knowledge of local epidemiology is necessary for establish more assertive control measures.

Influenza aviar: la gripa del pollo / Avian influenza: chicken's flu

La influenza aviar es causada por el virus de la influenza tipo A, perteneciente a la familia Ortomyxoviridae. Es un agente zoonotico que posee glicoproteínas de membrana con actividad de neuroraminidasa o hemaglutinina, que le otorgan gran variación antigénica llevando a la aparición de infección respiratoria aguda autolimitada tanto en animales como en humanos. En Colombia, ocurren brotes epidémicos de manera periódica, principalmente en épocas de lluvia (de marzo a junio y de septiembre a noviembre), pero se ha establecido que el virus circula de manera permanente durante todo el año. La aparición de nuevas cepas contra las cuales la población no posee inmunidad lleva a la aparición de pandemias. Se han documentado varias muertes en humanos en el sur de Asia relacionadas con la cepa H5N1, lo cual junto los antecedentes históricos, la epidemiología y la ecología de los reservorios naturales, permiten suponer la aparición de una nueva pandemia, que en caso de presentarse podría afectar entre el 15 por ciento y 35 por ciento de la población mundial. Las vacunas disponibles en la actualidad no ofrecen protección contra el virus H5N1. Asimismo, medicamentos antivirales como la amantadina no actúan sobre esta cepa y solo los inhibidores de la neuraminidasa como el Oseltamivir han demostrado alguna eficacia terapéutica