Paralysis of the external popliteal sciatic nerve associated with daptomycin administration.

WHAT IS KNOWN AND OBJECTIVE: Peripheral neuropathy has been associated with the administration of certain drugs. Few reports have described the association of daptomycin with the development of peripheral neuropathy, none of them with peroneal nerve involvement. CASE SUMMARY: We report a case of a 62-year-old man who developed external popliteal sciatic nerve paralysis after 22 days of therapy with daptomycin. WHAT IS NEW AND CONCLUSION: We present an uncommon and not previously reported adverse event. We have also analysed a possible alteration in a metabolic pathway (ABCB1 gene polymorphisms) that, in some patients, could explain certain drug adverse events. WHAT IS NEW AND CONCLUSION: We present an uncommon and not previously reported adverse event. We have also analysed a possible alteration in a metabolic pathway (ABCB1 gene polymorphisms) that, in some patients, could explain certain drug adverse events.

Is Streptococcus bovis a urinary pathogen?

The Streptococcus bovis group (SBG) comprises several microorganisms associated with human infections. They have been associated with bacteremia, endocarditis, biliary tract infection, meningitis, and colorectal cancer, but their role as urinary pathogens is not well known. The objective of this investigation was to discover the incidence and clinical significance of the bacteriuria associated with this complex. A retrospective analysis of all adult patients with bacteriuria caused by SBG during the period 1995-2012 was carried out. During the study period, SBG was isolated in 153 adult patients, who had a mean age of 67 years, most of them being women (80%). Most of our patients (65%) had some underlying disease, with urologic disease being the most common (37%), followed by diabetes mellitus (27%) and neurologic disease (25%). Among the 88 patients in whom we were able to correctly assess symptoms, 45% had asymptomatic bacteriuria, 35% had lower urinary tract infection, and 20% had upper urinary tract infection. In 14 cases (9%), SBG was also isolated in blood cultures. Most of the isolates of SBG (72%) were S. gallolyticus subsp. pasteurianus. All isolates were susceptible to penicillin, 98% to nitrofurantoin, and 77% to fosfomycin. Although SBG bacteriuria is uncommon, it should not always be taken as a contaminant, mainly when S. pasteurianus is isolated, because it may cause urinary tract infections and, occasionally, sepsis, whereas when S. gallolyticus is isolated from urine, it may be a marker of underlying endocarditis and colorectal cancer.

Differences between endocarditis caused by Streptococcus bovis and Enterococcus spp. and their association with colorectal cancer.

Streptococcus bovis group and Enterococcus spp. share phenotypic characteristics and intestinal habitat. Both have been associated with endocarditis and colorectal neoplasm (CRN). We studied all cases of endocarditis diagnosed between 1988 and 2014 in our centre and caused by S. bovis (109, 48.8 % of the bacteremia) and by Enterococcus spp. (36, 3.4 % of the bacteremia). Patients were seen until death or during a long-term follow-up, in order to rule out a concomitant CRN. The 109 cases of S. bovis endocarditis (SbIE) compared with the 36 caused by enterococci showed: a higher proportion of males (91 % vs. 72 %, p=0.005), more multivalvular involvement (28 % vs. 6 %, p=0.004), embolic complications (44 vs. 22 %, p=0.02) and colorectal neoplasm (64 % vs. 25 %, p=0.001). SbIE showed fewer co-morbidities (32 vs. 58 %, p=0.005), and less frequently urinary infection source (0 vs. 25 %, p=0.001) and healthcare-related infection (2 vs. 44 %, p=0.001). A total of 123 patients were followed up for an extended period (mean: 65.9 ± 57.5 months). During the follow-up, 6 of 28 (21 %) cases with enterococcal endocarditis and 43 of 95 (45.2 %, p=0.01) cases with SbIE developed a new CRN. These neoplasiae appeared a mean of 60.4 months later (range 12-181 months). Among the 43 cases with SbIE and CRN, 12 had had a previously normal colonoscopy and 31 had had a previous CRN and developed a second neoplasm. Cases of SbIE present important differences with those caused by Enterococcus spp. Colonoscopy must be mandatory both in the initial evaluation of SbIE, as during the follow-up period.

Is colonoscopy necessary in cases of infection by Streptococcus bovis biotype II?

The association of colorectal neoplasia (CRN) with Streptococcus bovis biotype I (SBI) infection is well recognized. However, this is not the case for Streptococcus bovis biotype II (SBII). We conducted this study in order to analyze the relationship between SBII and CRN. We analyzed all cases of bacteremia due to SBI (n = 99) and SBII (n = 36) diagnosed in our hospital (during the period 1988-2011) that were followed up with colonoscopy. In addition, we reviewed the literature (during the period 1982-2011) to select all cases of infection of SB that had undergone colonoscopy or other adequate form of colorectal examination. A multivariate analysis was performed to detect CRN risk factors in patients infected with SB. From the 223 cases of SB infection included in the analysis (135 from our institution and 88 from the literature review), 159 were due to SBI and 64 were caused by SBII. As compared with SBI, the SBII cases had a lower frequency of CRN (27 % vs. 67 %, p <0.001), advanced adenomas (8 % vs. 29 %, p <0.01), and carcinomas (6 % vs. 21 %, p <0.01). In a multivariate analysis, and after adjusting for age, sex, type of infection, and biotype, SBII infection was not associated with CRN: odds ratio (OR) = 0.17; 95 % confidence interval (CI) = 0.09 to 0.33. The only factor independently associated with CRN was SBI infection: OR = 5.7; 95 % CI = 3.0 to 10.9. The prevalence of CRN in patients infected with SBII is significantly lower than patients with SBI and does not appear to be higher than the CRN prevalence among the general population.

Vertebral osteomyelitis after spine instrumentation surgery: risk factors and management.

BACKGROUND: Vertebral osteomyelitis after spine instrumentation surgery (pVOM) is a rare complication. Most cases of infection occur early after surgery that involve skin and soft tissue and can be managed with debridement, antibiotics, and implant retention (DAIR). AIM: To identify pVOM risk factors and evaluate management strategies. METHODS: From a multicentre cohort of deep infection after spine instrumentation (IASI) cases (2010-2016), pVOM cases were compared with those without vertebral involvement. Early and late infections were defined (<60 days and >60 days after surgery, respectively). Multivariate analysis was used to explore risk factors. FINDINGS: Among 410 IASI cases, 19 (4.6%) presented with pVOM, ranging from 2% (7/347) in early to 19.1% (12/63) in late IASIs. After multivariate analysis, age (adjusted odds ratio (aOR): 1.10; 95% confidence interval (CI): 1.03-1.18), interbody fusion (aOR: 6.96; 95% CI: 2-24.18) and coagulase-negative staphylococci (CoNS) infection (aOR: 3.83; 95% CI: 1.01-14.53) remained independent risk factors for pVOM. Cases with pVOM had worse prognoses than those without (failure rate; 26.3% vs 10.8%; P = 0.038). Material removal was the preferred strategy (57.9%), mainly in early cases, without better outcomes (failure rate; 33.3% vs 50% compared with DAIR). Late cases managed with removal had greater success compared with DAIR (failure rate; 0% vs 40%; P = 0.067). CONCLUSION: Risk factors for pVOM are old age, use of interbody fusion devices and CoNS aetiology. Although the diagnosis leads to a worse prognosis, material withdrawn should be reserved for late cases or when spinal fusion is achieved.

[Health-related quality of life in patients recovered from COVID-19]. / Calidad de vida relacionada con la salud en pacientes recuperados de COVID-19.

INTRODUCTION: The presence of symptoms after acute SARS-CoV-2 infection is frequent and has an impact on patients' quality of life. The aim of this study is to assess the health-related quality of life of COVID-19 survivors and to ascertain which factors are related to worse results. METHODS: An observational, cross-sectional study has been performed, using, a telephone survey that was administered to all patients with COVID-19 from the first pandemic wave in our healthcare area 10months after the acute infection. Patients with dementia and nursing home residents were excluded. Health-related quality of life was assessed using the EQ-5D instrument and its índices EQ-VAS and EQ-Health Index. RESULTS: 443 answers were collected. Mean age was 54±16 and 38.4% of patients were male. The most affected domain was anxiety/depression (23.9% of patients) and mobility (16.5%). Mean global EQ-VAS score was 75.8±18.7, and mean EQ-Health Index was 0.884±0.174. Both VAS and Health Index scores were lower in females, patients older than 65 years, patients with comorbidities, and those who needed hospital admission during the acute infection. VAS scores in our sample were lower than in the general Spanish population, but similar to the scores in our region prior to the pandemic. Female sex, hospital admission, and a lower educational status were independently associated to lower EQ-Health Index scoring. CONCLUSION: While health self-perception is affected after COVID-19, this might not be directly related to the infection. There exist profiles of patients more prone to a worse quality of life in which interventions may be considered.

Suppressive antibiotic therapy in prosthetic joint infections: a multicentre cohort study.

OBJECTIVES: The aim was to describe the effectiveness of suppressive antibiotic treatment (SAT) in routine clinical practice when used in situations in which removal of a prosthetic implant is considered essential for the eradication of an infection, and it cannot be performed. METHODS: This was a descriptive retrospective and multicentre cohort study of prosthetic joint infection (PJI) cases managed with SAT. SAT was considered to have failed if a fistula appeared or persisted, if debridement was necessary, if the prosthesis was removed due to persistence of the infection or if uncontrolled symptoms were present. RESULTS: In total, 302 patients were analysed. Two hundred and three of these patients (67.2%) received monotherapy. The most commonly used drugs were tetracyclines (39.7% of patients) (120/302) and cotrimoxazole (35.4% of patients) (107/302). SAT was considered successful in 58.6% (177/302) of the patients (median time administered, 36.5 months; IQR 20.75-59.25). Infection was controlled in 50% of patients at 5 years according to Kaplan-Meier analysis. Resistance development was documented in 15 of 65 (23.1%) of the microbiologically documented cases. SAT failure was associated with age <70 years (sub-hazard ratio (SHR) 1.61, 95% CI 1.1-2.33), aetiology other than Gram-positive cocci (SHR 1.56, 95% CI 1.09-2.27) and location of the prosthesis in the upper limb (SHR 2.4, 95% CI 1.5-3.84). SAT suspension was necessary due to adverse effects in 17 of 302 patients (5.6%). CONCLUSIONS: SAT offers acceptable results for patients with PJI when surgical treatment is not performed or when it fails to eradicate the infection.

The clinical epidemiology and malignancies associated with Streptococcus bovis biotypes in 506 cases of bloodstream infections.

OBJECTIVES: To determine the incidence of Streptococcus bovis (Sb) biotypes causing bacteraemia and associated malignancies. METHODS: This is a retrospective analysis of patients with Sb bacteraemia, pulled out from a prospective surveillance protocol of bacteraemia cases, in three areas of Spain (1990-2013): a cattle area (Lugo), a fishing area (Ferrol) and an urban area (Barcelona). Colonoscopy and Sb biotypes (Sb-I and Sb-II) were determined in most cases. RESULTS: 506 patients with Sb bacteraemia; mean age 68.1 (±14.1) years, and 66.2% were males. The cattle area, compared with the fishing and urban areas, had higher incidence of bacteraemia by SbI (40.29 vs 9.38 vs 6.15 cases/10(6) person-years, P < 0.001) and bacteraemia by Sb-II (29.07 vs 9.84 vs 13.37 cases/10(6) person-years, P < 0.001). The Sb-I cases (n = 224), compared with Sb-II cases (n = 270), had greater rates of endocarditis (77.6% vs 9.6%, P < 0.001) and colorectal neoplasm (CRN) (50.9% vs 16.6%, P < 0.001), and smaller rates of biliary tract infection (2.2% vs 29.6%, P < 0.001) and non-colorectal malignancy (8.9% vs 31.4%, P < 0.001). CONCLUSION: There was a link between the cattle area and higher incidence of Sb bacteraemia. Sb-I differed from Sb-II cases in clinical findings and associated malignancies. Colonoscopy is mandatory in cases of endocarditis or bacteraemia caused by Sb-I.

Daptomycin plus fosfomycin versus daptomycin monotherapy in treating MRSA: protocol of a multicentre, randomised, phase III trial.

INTRODUCTION: Despite the availability of new antibiotics such as daptomycin, methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia continues to be associated with high clinical failure rates. Combination therapy has been proposed as an alternative to improve outcomes but there is a lack of clinical studies. The study aims to demonstrate that combination of daptomycin plus fosfomycin achieves higher clinical success rates in the treatment of MRSA bacteraemia than daptomycin alone. METHODS AND ANALYSIS: A multicentre open-label, randomised phase III study. Adult patients hospitalised with MRSA bacteraemia will be randomly assigned (1:1) to group 1: daptomycin 10 mg/kg/24 h intravenous; or group 2: daptomycin 10 mg/kg/24 h intravenous plus fosfomycin 2 gr/6 g intravenous. The main outcome will be treatment response at week 6 after stopping therapy (test-of-cure (TOC) visit). This is a composite variable with two values: Treatment success: resolution of clinical signs and symptoms (clinical success) and negative blood cultures (microbiological success) at the TOC visit. Treatment failure: if any of the following conditions apply: (1) lack of clinical improvement at 72 h or more after starting therapy; (2) persistent bacteraemia (positive blood cultures on day 7); (3) therapy is discontinued early due to adverse effects or for some other reason based on clinical judgement; (4) relapse of MRSA bacteraemia before the TOC visit; (5) death for any reason before the TOC visit. Assuming a 60% cure rate with daptomycin and a 20% difference in cure rates between the two groups, 103 patients will be needed for each group (α:0.05, ß: 0.2). Statistical analysis will be based on intention to treat, as well as per protocol and safety analysis. ETHICS AND DISSEMINATION: The protocol was approved by the Spanish Medicines and Healthcare Products Regulatory Agency (AEMPS). The sponsor commits itself to publishing the data in first quartile peer-review journals within 12 months of the completion of the study. TRIAL REGISTRATION NUMBER: NCT01898338.

Tuberculous spondylitis. A report of six cases and a review of the literature.

Tuberculous spondylitis in the United States is a disease of decreasing incidence and, when the incidence is compared to that of developing nations, affects an older population. The thoracic and lumbar spine is most frequently involved, and in advanced disease several vertebrae may be destroyed with resulting significant morbidity and mortality. The usual clinical presentation consists of fever, back pain, and nonspecific systemic symptoms of varying duration. More advanced disease presents with neurological deficits, kyphotic deformities of the spinal column, and paravertebral cold abscesses. Treatment has changed in the past 50 years not only because of the introduction of highly effective anti-tuberculous chemotherapeutic agents, but also because of the development of new surgical approaches. Controlled studies comparing various surgical and more conservative therapeutic regimens have been conducted within the past decade. Despite these new data, controversy remains regarding the indications for surgical treatment, since anti-tuberculous chemotherapy alone is successful in a large proportion of cases. However, in situations where rapid loss of neurologic function is evident or in which progressive deterioration in spinal cord function continues in the face of apparently adequate drug therapy, it appears that anterior surgical decompression of the spinal cord is indicated to prevent irreversible neurologic deficits. Needle biopsy of bone lesions under fluoroscopic or computed tomographic control is essential in the initial evaluation of patients in order to obtain cultural confirmation of tuberculosis.

Inflammatory pseudotumor of the sternum. A complication of polymer application during sternotomy repair.

A case of inflammatory pseudotumor of the sternum resulting from the application of polyurethane foam is discussed. The past use of polymers in bone repair is reviewed.

The split notochord syndrome with dorsal enteric fistula.

Split notochord syndrome with dorsal enteric fistula is an extremely rare congenital anomaly that may be associated with meningomyelocele or meningocele, and genitourinary anomalies. This case presented with an additional finding of bladder exstrophy, raising the possibility of a relationship between this syndrome and the OEIS complex.

Disease states affecting both liver and bone.

The skeletal system may be profoundly affected by chronic liver disease, resulting in a variety of conditions that may include osteomalacia, osteoporosis, hypertrophic osteoarthropathy, and osteonecrosis. Additionally, many diseases, including glycogen storage disease, Gaucher's disease, and hypervitaminosis A, cause concomitant changes in both liver and bone.

Bony overgrowths and abnormal calcifications about the spine.

The common phenomenon of osteophyte formation about the vertebral margins and on the vertebral bodies in certain instances connotes underlying disk degeneration. The classification and mechanism of formation of these bony excrescences are not totally clear in all instances, but there is frequent association with degenerative disk change. Distorted alignment of the spinal column as in scoliosis, and functional demands on the spine, play major roles in these abnormalities. The true degree of anatomic abnormality is greater than can be appreciated on the radiographs. Syndesmophytes are vertically orientated outgrowths of trabecular bone forming in the outer margins of the annulus fibrosus and related to repeated episodes of inflammation and repair. They are classically seen in ankylosing spondylitis and colonic spondyloarthropathy. Bulky paravertebral excrescences are more likely to be found in psoriatic arthritis and Reiter's syndrome. Other bony excrescences in the spine were also discussed. OPLL is a progressive disease that can result in severe radicular and myelopathic symptoms. Although OPLL appears to have an unexplained predilection for Asians, it affects all races. Classically diagnosed on lateral radiographs of the cervical spine, it is best imaged with CT. Proper evaluation of the extent of the entire ossified mass and its effect on the spinal cord is crucial in the planning of adequate therapy.

Subcutaneous recombinant human erythropoietin in hemodialysis and continuous ambulatory peritoneal dialysis.

We compared the effect of twice weekly subcutaneous recombinant human erythropoietin (SC rHuEPO) in two groups of patients treated with a starting dose of 80 U/kg body weight/week: group I, 7 hemodialysis (HD) patients; group II, 8 continuous ambulatory peritoneal dialysis (CAPD) patients. In a third group (group III) of 4 patients transferred from HD to CAPD with anemia previously corrected with intravenous (IV) rHuEPO, we studied the changes in the maintenance SC dose to maintain the same hemoglobin. In groups I and II the mean SC doses required to correct anemia and to maintain hemoglobin/hematocrit levels were similar; the mean time for the correction of anemia was significantly longer in HD patients (p = 0.032). In group III the maintenance SC rHuEPO does was reduced to more than 50% at 12 weeks of CAPD. Subcutaneous rHuEPO is effective in reversing anemia in HD and CAPD patients, but it takes longer to correct anemia in HD with the same initial SC rHuEPO low dose. CAPD patients need lower doses of SC rHuEPO than HD patients in IV therapy to maintain the same hemoglobin levels.

The role of gallium and bone scintigraphy in disseminated coccidioidomycosis.

The osseous lesions of disseminated coccidioidomycosis may be detected by bone but not by gallium scintigraphy or vice versa. This case emphasizes the need for performing both bone and gallium scans to avoid missing potentially serious bone lesions.

Strangulated volvulus of the sigmoid colon with inviable mucosal appearance in a non-surgical patient. Endoscopic devolvulation.

Colonoscopy is presently always performed before surgical management of a volvulus in the sigmoid colon. It leads to know the viability of the mucosa and, when possible, to resolve the volvulus conservatively. Besides, with endoscopic control, we can place a decompression tube proximal to the volvulated sigmoid colon, favouring a non-surgical resolution. With this conservative approach it is possible to overcome the acute period, and to restore the viability of the sigmoid wall, waiting for a definitive surgical management with less morbidity and mortality. Only with endoscopy, revolvulation does occur in 35-50% of cases. We present the clinical case of a sigmoid volvulus with compromised sigmoid wall in an 82-year-old man with several clinical problems contraindicating surgery. Endoscopic devolvulation with tube placement was adequate to resolve this sigmoid volvulus.

[Cyclosporin A--a therapeutic alternative in giant-cell arteritis?]. / Ciclosporina A--alternativa terapêutica na arterite de células gigantes?

Cyclosporine A (CyA) is an immune modulator that may treat immune diseases. The authors present two cases of temporal arteritis treated with CyA; the two patients improved very quickly and after the first six or eight weeks of treatment there were no clinical or laboratory signs of inflammation. As to adverse effects there was a moderate increase in serum creatinine and arterial pressure levels which were controlled when the CyA dosage was reduced. In view of the good results achieved in these two patients, the authors concluded that CyA may be an alternative therapy for giant-cell arteritis and that this hypothesis should be further investigated in a larger group of patients.

[Cutaneous infection with the cytomegalovirus virus in AIDS patients]. / Infecção cutânea por vírus citomegálico em doentes com SIDA.

Cutaneous cytomegalovirus (CMV) infection has been observed in a variety of nonspecific skin lesions. Because of this fact, its diagnosis is rare and frequently accidental. The presence of the virus has also been observed in apparently normal skin, from both a clinical and histological point of view. In this context, skin biopsy and immunohistochemistry are often the first means of diagnosis of systemic CMV infection. In 180 skin biopsies carried out on HIV patients in the Infectious and Parasitic Diseases Unit, typical histopathological findings of CMV infection in a nonspecific skin lesion were observed in only one patient. Although the patient showed no extracutaneous manifestations at this time, she died soon after this diagnosis. Because of this fact, we review the literature and discuss the difficulties and implications of the diagnosis of cutaneous CMV infection in AIDS patients.