Infection site is predictive of outcome in acute lung injury associated with severe sepsis and septic shock.

BACKGROUND AND OBJECTIVE: Sepsis is a leading cause of acute lung injury (ALI); however, the characteristics and outcome of sepsis-associated ALI are poorly understood. We aimed to elucidate factors that predict patient outcome in sepsis-associated ALI. METHODS: Secondary analysis of a multicenter, prospective, observational study was performed. RESULTS: Among 624 patients with severe sepsis and septic shock, 251 (40.2%) fulfilled the definition of American-European Consensus Conference definition of ALI. All-cause 28-day and in-hospital mortalities were 30.7% and 38.6%, respectively. More than 40% of ALI patients had neurological, cardiovascular and haematological dysfunctions or disseminated intravascular coagulation, all of which were associated with higher mortality. We report a significant correlation between infection site and mortality in patients with ALI, but not in those without ALI. The proportion of ALI was significantly higher in pulmonary sepsis; further, a complication of ALI was associated with higher mortality in sepsis from pulmonary and other sources, but not in abdominal sepsis. Among the other sepsis sites, urinary tract, central nervous system, catheter-related and undetermined foci of infection had worse outcomes when associated with ALI. None of the individual severe sepsis bundles, including fluid resuscitation and early antibiotic administration, correlated with mortality. Compliance with a set of sepsis management bundles was associated with better outcomes. CONCLUSION: In severe sepsis and septic shock, the proportion and effect on outcome was not uniform among infection sites. The infection site was predictive of outcome in patients with ALI but not in those without ALI.

[An update on focal infection of oral origin]. / Point actuel sur l'infection focale d'origine buccodentaire.

Focal infection of oral origin means that an oral infectious focus may have widespread effects. This concept remains controversial since it is difficult to prove the oral origin of germs responsible for an extra-oral infection. Experiments on animal models and clinical studies suggested several physiopathological mechanisms: bacteremia, toxinic and immunological mechanisms. Various operations induce the passage of bacterial flora (transcytosis) and its toxins into the bloodstream: oral care, chewing, or tooth brushing. Bacteremia is worsened by poor oral hygiene or an infection. The germs are usually destroyed by the host's reticuloendothelial system in a few minutes, but the presence of a valvular disease or a weak immune system favors focal infection. Besides infectious endocarditis, this may concern cardiovascular diseases, lung infections, prematurity and hypotrophy, diabetes, prosthetic infections, cerebral abscesses, etc. This update is based on literature review, selected according to its high level of scientific proof, as well as on a selected choice of consensus conferences. The current recommendation is to limit antibiotic prophylaxis to the high bacteremia risk procedures and to patients highly at risk of developing a focal infection.

Enterococcus faecalis in blood cultures-a prospective study on the role of persistent bacteremia.

Enterococcus faecalis can cause infective endocarditis and other complicated infections. We prospectively investigate the incidence of persistent bacteremia with E. faecalis. Of 50 episodes with monomicrobial E. faecalis bacteremia the control blood culture after 48 to 72 hours was positive in 5 episodes (10%) of which 4 had a complicated focal infection.

[Predictive markers of acute focal bacterial nephritis. A multicentre case-control study]. / Marcadores predictivos de nefritis focal bacteriana aguda. Estudio multicéntrico casos-control.

INTRODUCTION: Acute focal bacterial nephritis is an interstitial bacterial infection, localised in the renal parenchyma, which can be more serious than acute pyelonephritis. The aim of this study is the analysis of predictive factors that may lead to its early diagnosis, which is essential for an adequate therapeutic approach. PATIENTS AND METHODS: A retrospective, multicentre case and control study. The participant centres were hospitals in Castellon and Valencia. The study period was 2010-2018, with the cases being patients with focal bacterial nephritis and the patients with pyelonephritis as controls. RESULTS: A total of 158 (1:1) patients were included. The median age of the cases was 2 years and there were 75% females. There were no differences in the clinical presentation. In the univariate analysis, focal nephritis was associated with malformations of the urinary tract, bacteraemia, the neutrophil count, and procalcitonin, as well as febrile convulsions of borderline significance. Procalcitonin values ≥2 ng/ml had an OR of 4.9 (95%CI; 1.77-13.85) of presenting with focal nephritis. In the multivariate analysis, the urological malformations still maintained statistical significance and borderline significance for procalcitonin. CONCLUSIONS: The urinary tract malformations predispose the development of focal bacterial nephritis. In patients with a urinary tract infection and predictive factors of acute focal bacterial nephritis it would be worthwhile performing a renal Doppler ultrasound in the acute phase for its appropriate diagnosis and treatment.

Incremental value of metagenomic next generation sequencing for the diagnosis of suspected focal infection in adults.

OBJECTIVES: Microbiological diagnosis is essential during clinical management of focal infections. Metagenomic next generation sequencing (mNGS) has been reported as a promising diagnostic tool in infectious diseases. However, little is known about the clinical utility of mNGS in focal infections. METHODS: We conducted a single-center retrospective study to investigate impact of mNGS on focal infection diagnosis and compared it with conventional methods, including culture, pathological examination, Xpert MTB/RIF, etc. 98 suspected focal infections cases were enrolled, and medical records were reviewed to determine their rates of detection, time-to-identification, and clinical outcomes. RESULTS: mNGS showed a satisfying diagnostic positive percent agreement of 86.30% (95% CI: 75.79-92.88%) in a variety of tissues, compared to 45.21% (95% CI: 33.68-57.24%) for culture and 57.53% (95% CI: 45.43-68.84%)f for conventional methods (p < 0.0125), and detected an extra 34 pathogenic microorganisms. Time requirement for pathogen identification using mNGS ranges from 31 h to 55 h, which showed an advantage over culture. (82.36 h; 95%CI: 65.83, 98.89; P < 0.05) CONCLUSIONS: mNGS showed promising potential in pathogenic diagnosis during focal infections and might enable clinicians to make more timely and targeted therapeutic decisions.

Acute focal nephritis: its true sonographic face.

BACKGROUND: Acute focal nephritis is an inflammatory process of the renal parenchyma affecting principally the cortex of the kidney. It is considered a midpoint in the spectrum of upper urinary tract infections, ranging from uncomplicated pyelonephritis to intrarenal abscesses. Until recently the hyperechoic sonographic appearance of this lesion was considered uncommon. OBJECTIVES: To determine the relative prevalence of hyperechoic and hypoechoic sonographic appearance of focal renal lesions in patients with the clinical diagnosis of acute pyelonephritis and to correlate the findings with those of the color Doppler examinations. METHODS: We reviewed the sonograms of 367 patients hospitalized with the clinical diagnosis of acute pyelonephritis. The sonograms were reviewed for acute renal inflammatory changes. When a focal lesion was detected, we noted the echogenicity, side, form, location and color Doppler characteristics. RESULTS: Abnormal sonographic findings related to the infection were found in 78 cases. In 52 patients a focal lesion was diagnosed. Forty-seven focal lesions appeared hyperechoic related to the adjacent parenchyma. These lesions were more frequently located at the upper pole and were wedge-shaped in most of the cases. The areas appeared hypo/avascular on the color Doppler examination. CONCLUSIONS: Our data suggest that the most common appearance of acute focal nephritis is an area of increased echogenicity in the parenchyma of the affected kidney.

[Erysipelas-like dermatitis of the legs revealing aspergilloma of the maxillary sinus]. / Dermatite érysipéloïde des membres inférieurs révélant un aspergillome du sinus maxillaire.

BACKGROUND: Skin signs is associated with Aspergillus are rare and are seen principally in immunodepressed patients. Distinction is generally made between primary skin aspergillosis, caused by direct cutaneous inoculation with the offending organism, and secondary skin aspergillosis, associated with peripheral emboli from an area of chronic pulmonary or sinus mycetoma. There have been rare reports of indirect satellite skin signs resulting from Aspergillus infection, and below we present such a case. PATIENTS AND METHODS: A 40 year-old immunocompetent man consulted for erysipeloid plaques on the lower limbs recurring over a period of seven months. X-rays and CAT scans of the sinus demonstrated asymptomatic axillary sinusitis probably caused by Aspergillus. The diagnosis was confirmed by surgery, which resulted in cure without additional antifungal treatment. The inflammatory syndrome subsided and after 15 months, there was no recurrence of lesions. DISCUSSION: The absence of relapse following treatment of the focus of aspergillosis forms a major argument in favour of a causal relationship between the erysipeloid dermatitis and the sinus mycotic infection. The hypothesis of a septic embologenic mechanism within the sinus was abandoned in favour of a mechanism similar to streptococcal nodular erythema, seen in diseases involving immune complexes, possibly caused by allergy to Aspergillus proteins. This case history demonstrates the existence of satellite skin signs of Aspergillus infection indicative of neither primary nor secondary aspergillosis.

Marcadores predictivos de nefritis focal bacteriana aguda. Estudio multicéntrico casos-control / Predictive markers of acute focal bacterial nephritis. A multicentre case-control study

INTRODUCCIÓN: La nefritis focal bacteriana aguda es una infección intersticial bacteriana, localizada en el parénquima renal, que entraña mayor gravedad que la pielonefritis aguda. El objetivo del estudio es el análisis de factores predictivos que permitan su diagnóstico precoz, fundamental para un adecuado abordaje terapéutico. PACIENTES Y MÉTODOS: Estudio multicéntrico de casos y control retrospectivo. Centros participantes: hospitales de Castellón y Valencia. Periodo de estudio: 2010-2018. Casos: nefritis focal bacteriana. Controles: pielonefritis aguda. RESULTADOS: Se incluyó a un total de 158 pacientes (1:1). La mediana de edad de los casos fue 2 años. El 75% de sexo femenino. No existieron diferencias en la presentación clínica. En el análisis univariante la nefritis focal se relacionó con malformaciones del tracto urinario, bacteriemia, recuento de neutrófilos y la procalcitonina, así como las convulsiones febriles en el límite de la significación. Valores de procalcitonina ≥ 2 ng/ml tiene una OR de 4,9 (IC del 95: 1,77-13,85) de presentar nefritis focal. En el análisis multivariante las malformaciones urológicas mantuvieron la significación estadística y la procalcitonina en el límite de la significación. CONCLUSIONES: Las malformaciones del tracto urinario predisponen al desarrollo de nefritis focal bacteriana. Ante pacientes con infección del tracto urinario y factores predictivos de nefritis focal bacteriana aguda, sería recomendable la realización de una ecografía Doppler renal en fase aguda para un diagnóstico y un tratamiento adecuado

INTRODUCTION: Acute focal bacterial nephritis is an interstitial bacterial infection, localised in the renal parenchyma, which can be more serious than acute pyelonephritis. The aim of this study is the analysis of predictive factors that may lead to its early diagnosis, which is essential for an adequate therapeutic approach. PATIENTS AND METHODS: A retrospective, multicentre case and control study. The participant centres were hospitals in Castellon and Valencia. The study period was 2010-2018, with the cases being patients with focal bacterial nephritis and the patients with pyelonephritis as controls. RESULTS: A total of 158 (1:1) patients were included. The median age of the cases was 2 years and there were 75% females. There were no differences in the clinical presentation. In the univariate analysis, focal nephritis was associated with malformations of the urinary tract, bacteraemia, the neutrophil count, and procalcitonin, as well as febrile convulsions of borderline significance. Procalcitonin values ≥ 2 ng/ml had an OR of 4.9 (95% CI; 1.77-13.85) of presenting with focal nephritis. In the multivariate analysis, the urological malformations still maintained statistical significance and borderline significance for procalcitonin. CONCLUSIONS: The urinary tract malformations predispose the development of focal bacterial nephritis. In patients with a urinary tract infection and predictive factors of acute focal bacterial nephritis it would be worthwhile performing a renal Doppler ultrasound in the acute phase for its appropriate diagnosis and treatment

Focal neurological disease in patients with acquired immunodeficiency syndrome.

Focal neurological disease in patients with acquired immunodeficiency syndrome may be caused by various opportunistic pathogens and malignancies, including Toxoplasma gondii, progressive multifocal leukoencephalopathy (PML), cytomegalovirus (CMV), and Epstein-Barr virus-related primary central nervous system (CNS) lymphoma. Diagnosis may be difficult, because the findings of lumbar puncture, computed tomography (CT), and magnetic resonance imaging are relatively nonspecific. Newer techniques have led to improved diagnostic accuracy of these conditions. Polymerase chain reaction (PCR) of cerebrospinal fluid specimens is useful for diagnosis of PML, CNS lymphoma, and CMV encephalitis. Recent studies have indicated the diagnostic utility of new neuroimaging techniques, such as single-photon emission CT and positron emission tomography. The combination of PCR and neuroimaging techniques may obviate the need for brain biopsy in selected cases. However, stereotactic brain biopsy, which is associated with relatively low morbidity rates, remains the reference standard for diagnosis. Highly active antiretroviral therapy has improved the prognosis of several focal CNS processes, most notably toxoplasmosis, PML, and CMV encephalitis.

Role of the complete blood count in detecting occult focal bacterial infection in the young febrile child.

Previous studies of the value of the complete blood count (CBC) in distinguishing viral from bacterial infection in young febrile children have failed to exclude children with clinically evident bacterial infection and thus have inflated the positive predictive value of the test for occult focal infection. We prospectively studied 2492 children 3-24 months of age who presented to a children's hospital emergency department between March 1989 and August 1990 with fever (> or = 38.0 degrees C) of acute (< or = 4 days) onset but no evident bacterial focus of infection, 433 (17.4%) of whom received a CBC. We also carried out an 8-year retrospective analysis to estimate prior, or pre-test, probabilities (prevalences) and examine CBC results for rare occult bacterial infections (meningitis, osteomyelitis, and septic arthritis). Estimated prior probabilities for the four most common categories of infection that can be diagnosed at the initial visit were: non-pneumonitic viral infection, 88.6% in boys and 86.0% in girls; pneumonia, 8.5% in both sexes; urinary tract infection (UTI), 3.0% in boys and 5.5% in girls; and bacterial meningitis, 0.0066% in both sexes. The likelihood (sensitivity) of a total white blood cell (WBC) count > or = 15,000/mm3 was 25.5, 64.5, 62.5, and 50.0% for viral infection, pneumonia, UTI, and meningitis, respectively. Among children with a high total white blood cell count, neither a total polymorphonuclear count > or = 10,000/mm3 nor a band count > or = 500/mm3 was associated with significantly elevated likelihoods for occult pneumonia or UTI, a finding confirmed by multiple logistic regression analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Suppurative thrombophlebitis in children: a ten-year experience.

OBJECTIVE: To determine the clinical and diagnostic features, complications, management and prevention of superficial suppurative thrombophlebitis (ST) in children < 18 years of age. STUDY DESIGN: A retrospective review of medical records was performed for patients in two urban hospitals from January 1, 1985, through June 30, 1995, with a discharge diagnosis of phlebitis. RESULTS: We identified 21 patients, including 12 neonates, with ST. The majority had underlying medical conditions or preceding invasive procedures and administration of broad spectrum antibiotics or total parenteral nutrition as possible predisposing factors. More than two-thirds had localizing signs (swelling, erythema, induration or a palpable cord); one-third had purulent drainage from the vein. Septicemia was present in one-third of patients. Fever and tenderness were present in older children. Nearly one-half had involvement of an upper extremity. Cultures of vein (63%), blood (67%) or abscess (86%) grew pathogens in most. Gram-positive organisms were predominant; Staphylococcus aureus was isolated from 44%, Gram-negative enterics from 16.7% and Candida species from another 16.7% of patients. Eleven children had vein excision, whereas 10 had only incision and drainage. Complications, including death in one patient, occurred in 33% but could not be correlated with age or method of surgical intervention. CONCLUSIONS: ST is a rare but serious nosocomial infection in infants and children that results in substantial morbidity. It should be suspected in any hospitalized child who is or was receiving intravenous fluids and who has fever, localizing signs or persistent bacteremia. Prompt vein excision, with adjunctive antimicrobial therapy, is the recommended treatment.

Descending cervical mediastinitis.

Descending cervical mediastinitis is an uncommonly reported presentation of infection originating in the head or neck and descending into the mediastinum, which is fraught with impressive morbidity and mortality rates of 30% to 40% or more. We present the INOVA-Fairfax-Alexandria Hospital experience with descending cervical mediastinitis, January 1, 1986, to April 1, 1997; in addition we review the English-language medical and surgical literature with regard to this entity. Computed tomography and magnetic resonance imaging serve to aid both diagnosis and management. The application of broad-spectrum antibiotics should initially be empiric, with an eye to coverage of mixed aerobic and anaerobic infections. Definitive treatment mandates early and aggressive surgical intervention. All affected tissue planes, cervical and mediastinal, must be widely debrided, often leaving them open for frequent packing and irrigation. The treating physician must remain always alert to the further extension of infection, which, if it occurs, must be further debrided and drained. Tracheostomy serves a dual role of further opening cervical fascial planes and securing an often compromised airway.

Potential sites of infection that develop in febrile neutropenic patients.

Three hundred episodes of neutropenia were reviewed for the occurrence of potential sites of infection. Ninety sites (30 per cent) were identified at the onset of fever independent of initial bacteraemia which was encountered in 104 episodes (35%) and predominantly involved Gram-positive cocci. A further 90 sites were recorded involving mainly the lower respiratory tract (58%) and skin and soft tissue (18%). These changes evolved significantly later (mean of 5.1 and 4.3 days respectively) than did other foci which mainly presented at the onset of fever (p < 0.01). However the infectious aetiology was established in only 54 cases overall with fungi being responsible for 25 of 45 cases of lower respiratory tract infections with a known microbiological aetiology. The mortality associated with initial bacteraemia, focus at onset and unexplained fever was 11-14% while that associated with the development of a subsequent focus was 28% with lung infiltrates carrying the worst prognosis. Therefore rather than being seen as a final solution for possible infectious complications, empiric therapy provides an opportunity for daily review of the patient thereby increasing the likelihood of both explaining initial fever and diagnosing subsequent infection.

Oral cavity and pharynx.

Imaging of the oral cavity and pharynx often is required in three settings: assessment of an inflammatory mass in association with odontogenic, tonsillar, or pharyngeal infections; determination of the cause of a submucosal mass; and staging of squamous-cell carcinomas. Spread of infection from the oral cavity and pharynx can lead to abscesses in the masticatory space, the retropharyngeal compartment, and in a parapharyngeal location. Submucosal masses include congenital cysts (thyroglossal and dermoid), benign neoplasms (hemangioma, schwannomas, pleomorphic adenomas juvenile angiofibromas), inflammatory cysts (mucous retention cysts, ranulas), and pseudotumors (osteophytes, carotid arteries). Staging of squamous-cell carcinomas must focus on deep invasion, spread to the brain, nerves, mandible, prevertebral muscle, and pre-epiglottic fat.

Abscess formation within a parasagittal meningioma. Case report.

The authors present the case of a 78-year-old woman who developed right lower-extremity paralysis after a focal seizure. Neuroradiological studies revealed a small parasagittal meningioma, which at the time of resection was found to contain a bacterial intratumoral abscess secondary to Proteus mirabilis. This is only the second reported case of intratumoral abscess formation in a meningioma and the first such occurrence to be reported in an otherwise healthy, immunocompetent individual.

Focal bacterial nephritis (lobar nephronia) presenting as renal mass.

A focal infection of the kidney can cause a diagnostic dilemma by mimicking a neoplasm. We describe a case of focal bacterial nephritis (acute lobar nephronia) caused by Escherichia coli in which the diagnosis was confirmed only after surgical exploration. Although the patient had fever on admission, urine and blood cultures were negative and fine needle aspiration of the kidney could not rule out a well-differentiated carcinoma.

[Ultrasound in acute renal infections (author's transl)]. / Einsatzmöglichkeit der Sonographie bei akuten entzündlichen Nierenerkrankungen.

Ultrasound examinations were analysed in 24 patients with acute renal infections (pyelonephritis, focal pyelonephritis, renal abscess, pyonephrosis). Ultrasound examination is normal in mild inflammatory involvement of parenchyma, diffuse enlargement of parenchyma with echo-poor structure is found in severe involvement of parenchyma, localized echo-poor swelling of parenchyma is seen in focal pyelonephritis. Fever and flank pain are common to acute ureteral obstruction and acute pyelonephritis and ultrasound can differentiate between these diseases. Among mass lesions ultrasound can distinguish between focal pyelonephritis and abscess but cannot differentiate between tumor and focal pyelonephritis.

Orthopedic symptoms in pustular bacterid (pustulosis palmaris et plantaris): Tietze's syndrome and arthritis of manubriosternal joint due to focal infection.

Painful orthopedic symptoms in the sternal area, such as arthritis of the manubriosternal and sternoclavicular joint or Tietze's syndrome, were found in 14 of 132 cases of pustulosis palmaris et plantaris. The majority of the pustulosis palmaris et plantaris patients with orthopedic symptoms had skin eruptions not only on the palms and soles, but also on the backs of the hands and feet, the arms, the legs and the trunk. Such cases were usually accompanied by elevation of the erythrocyte sedimentation rate, leucocytosis, changes in serum globulin, and also pyrexia at the time of exacerbation. The skin and orthopedic symptoms often worsened after acute exacerbation of the focal infection, and occasionally responded to tonsillectomy or chemotherapy with antibiotics, which is suggestive of the probable cause of the bacterid.

Measurement of serum amyloid A in the neonatal foal using a latex agglutination immunoturbidimetric assay: determination of the normal range, variation with age and response to disease.

This paper describes the use of a latex agglutination assay to measure serum amyloid A (SAA) in the neonatal foal. The normal range and response to clinical disease was determined. This retrospective study evaluated SAA concentrations over the first 3 days postpartum of 226 Thoroughbred foals judged to be clinically healthy. The normal range for each day was determined; levels were found to be significantly highest on Day 2 (Day 1 vs. Day 2 P<0.0001). The 95th percentile for Days 1-3 was 27.1 mg/l. Clinical records of 133 foals, presented as first or second opinion cases, were evaluated. Foals were divided into 4 groups; septicaemia (S), focal infection (FI), failure of passive transfer (FPT) and noninfectious disease (NI). There was a statistically significant difference (P<0.0001) between SAA concentrations of control foals compared to Groups S and FI. There was no statistically significant difference between controls and Groups FPT and NI. When Group NI was compared to Groups S and FI, there was a statistically significant difference (P<0.0001). The authors suggest that SAA determined by this latex agglutination assay might be a helpful aid in the diagnosis of septicaemia and focal infection in neonatal foals; levels >100 mg/l are highly suggestive of infection in young foals.

Pneumococcal bacteremia and focal infection in young children.

We reviewed a consecutive case series of 178 immunocompetent children aged 3-36 months without central venous lines who had blood cultures positive for Streptococcus pneumoniae by either of paired broth and quantitative culture methods. The incidence of accompanying focal infection was significantly greater in patients with > 10 colony-forming units (cfu)/mL than in patients with < or = 10 cfu/mL (30.4% vs 12.9% respectively, p = 0.04). No significant relationships existed between the magnitude of bacteremia and the age, gender, presenting temperature, interval until the blood culture turned positive, total peripheral blood white cell count, absolute neutrophil count, or absolute band count. Overall, the quantitative method detected 59/178 (33.1%) of the isolates, including five isolates (2.8%) that the broth method failed to detect.