Classical fever of unknown origin in 21 countries with different economic development: an international ID-IRI study

Fever of unknown origin (FUO) is a serious challenge for physicians. The aim of the present study was to consider epidemiology and dynamics of FUO in countries with different economic development. The data of FUO patients hospitalized/followed between 1st July 2016 and 1st July 2021 were collected retrospectively and submitted from referral centers in 21 countries through ID-IRI clinical research platform. The countries were categorized into developing (low-income (LI) and lower middle-income (LMI) economies) and developed countries (upper middle-income (UMI) and high-income (HI) economies). This research included 788 patients. FUO diagnoses were as follows: infections (51.6%; n = 407), neoplasms (11.4%, n = 90), collagen vascular disorders (9.3%, n = 73), undiagnosed (20.1%, n = 158), miscellaneous diseases (7.7%, n = 60). The most common infections were tuberculosis (n = 45, 5.7%), brucellosis (n = 39, 4.9%), rickettsiosis (n = 23, 2.9%), HIV infection (n = 20, 2.5%), and typhoid fever (n = 13, 1.6%). Cardiovascular infections (n = 56, 7.1%) were the most common infectious syndromes. Only collagen vascular disorders were reported significantly more from developed countries (RR = 2.00, 95% CI: 1.19-3.38). FUO had similar characteristics in LI/LMI and UMI/HI countries including the portion of undiagnosed cases (OR, 95% CI; 0.87 (0.65-1.15)), death attributed to FUO (RR = 0.87, 95% CI: 0.65-1.15, p-value = 0.3355), and the mean duration until diagnosis (p = 0.9663). Various aspects of FUO cannot be determined by the economic development solely. Other development indices can be considered in future analyses. Physicians in different countries should be equally prepared for FUO patients.

Pseudomonas aeruginosa nosocomial meningitis following spinal anesthesia – still a significant treatment dilemma

Background:

Infections of central nervous system after spinal anesthesia nowadays are a rarity; however, their presence might be of concern.

Case Description:

We report the case of lateral ventricular empyema treated unsuccessfully with parenteral antibiotic therapy, with the clinical signs of a persisting meningitis. After several lumbar taps suggesting an infection, Pseudomonas aeruginosa was isolated and a brain magnetic resonance imaging find out the collection in the left horn of the lateral ventricle. An intrathecal/intraventricular antibiotic therapy with colistin proved highly effective combined with an extra ventricular drainage to deal with the hydrocephaly.

Conclusion:

Clinicians should take into account even uncommon infectious agents while facing the picture of a meningitis otherwise nonresponsive to empiric or standard therapy.

P08 The difficulty of Pseudomonas aeruginosa eradication in a post-spinal anaesthesia meningitis

Background

Meningitis and ventriculitis due to Pseudomonas aeruginosa are uncommon. They are commonly secondary hospital-onset and typically related to neurosurgical procedure. Previous studies have shown P. aeruginosa to be responsible for 1%–18% of nosocomial meningitis cases. Both treatment failure and relapses are known to occur, and the recorded mortality is high, approaching 80% in some studies.

Objectives

We report a case of P. aeruginosa meningitis in a 26-year-old woman following spinal anaesthesia for caesarean section, its clinical characteristics, treatment challenges in the era of high generation antibiotics and the outcomes.

Results

A 26-year-old woman was hospitalized after 1 week of her third child delivery by caesarean section with spinal anaesthesia and 3 days after high fever and headache. Lumbar puncture was performed immediately, and leucocyte cell count was 723 cell/dL with 94% segmented neutrophils. CSF glucose was very low, and protein was 420 mg/dL. P. aeruginosa was isolated and it was susceptible to all antibiotics of standard panel. Cranial and lumbar region CT scans were normal. We modified empirical treatment and started ceftazidime and gentamicin. Three days after de-hospitalization in improved condition, she had high fever and strong headache and came back to hospital. We started treatment with imipenem and ciprofloxacin and 2 months after we performed several lumbar punctures, cranial MRIs and changed different antibiotic regimens with third generation cephalosporins, aminoglycosides, carbapenems and colistin; her clinical situation such as headache and fever and CSF did not show any sign of improvement. Susceptible P. aeruginosa was isolated each time we examined her CSF. She decided to leave the hospital and 2 weeks after her headache worsened and a convulsive attack happened. The cranial MRI showed hydrocephaly and a white precipitate (pus) in the left lateral ventricle. An extraventricular drain helped to resolve hydrocephaly and intraventricular colistin was injected until CSF was sterilized. After 1 month she was in a very good condition and a ventriculo-peritoneal shunt was placed.

Conclusions

P. aeruginosa meningitis was associated with some treatment difficulties. Even after an early nosological and microbiological diagnosis and an appropriate choice of antibiotics, based on bacterial meningitis treatment criteria and antibiogram, we couldn't eradicate the bacteria from CSF. To achieve success in this nosocomial infection from a not careful asepsis, sometimes a prolonged antibiotic and local treatment with intraventricular or intrathecal therapy is needed.

The Importance of Nutraceuticals in COVID-19: What's the Role of Resveratrol?

Since COVID-19 has affected global public health, there has been an urgency to find a solution to limit both the number of infections, and the aggressiveness of the disease once infected. The main characteristic of this infection is represented by a strong alteration of the immune system which, day by day, increases the risk of mortality, and can lead to a multiorgan dysfunction. Because nutritional profile can influence patient’s immunity, we focus our interest on resveratrol, a polyphenolic compound known for its immunomodulating and anti-inflammatory properties. We reviewed all the information concerning the different roles of resveratrol in COVID-19 pathophysiology using PubMed and Scopus as the main databases. Interestingly, we find out that resveratrol may exert its role through different mechanisms. In fact, it has antiviral activity inhibiting virus entrance in cells and viral replication. Resveratrol also improves autophagy and decreases pro-inflammatory agents expression acting as an anti-inflammatory agent. It regulates immune cell response and pro-inflammatory cytokines and prevents the onset of thrombotic events that usually occur in COVID-19 patients. Since resveratrol acts through different mechanisms, the effect could be enhanced, making a totally natural agent particularly effective as an adjuvant in anti COVID-19 therapy.

P12 Important early prognostic laboratory indicators for COVID-19 mortality

Background

COVID-19 has been marked as a highly pathogenic coronavirus of COVID-19 disease which has caused a pandemic into the human population, with a different course in different people, which contributed to the death of approximately over 5.02 million confirmed cases worldwide up till now. For this reason, it is quite important to have the earliest possible evaluation of laboratory-assisted indicators, especially for mortality risk prediction in developing countries, in addition to other clinical and imaging evaluations in order every physician to make the right medical decision.

Methods

In total, 277 patients of Infectious Diseases Hospital, UHC “Mother Teresa” were enrolled. All of them tested positive for COVID-19. We evaluated indicators such as d-dimer (N = 0–500 μg/L), lactate dehydrogenase LDH (N = 95–200 U/L) and the neutrophil/lymphocyte ratio (control group = 1.7 ± 0.392) in two groups of patients, the first one of 144 patients who were discharged from the hospital and the second one of 133 patients who died.

Results

What we observed was that the results were different for every test we performed in each group. Neutrophil/lymphocyte ratio was 8.69 ± 4.9 for the first group versus 14.7 ± 12.3 for the second one, P<0.05 (P = 0.013), LDH = 427 ± 241 versus 715 ± 347, P<0.05 (P = 0.0002), d-dimer = 1387 ± 763 versus 2650 ± 1322, P>0.05 (P = 0.28).

Conclusions

In addition to LDH as a prognostic factor, the neutrophil/lymphocyte ratio was considered as a low cost examination for severe prognosis and mortality risk (P<0.05), which can also serve as an alert for primary services for patient hospitalization, especially in developing countries after his clinical and image evaluation.

Risk factors for poor outcome of patients with Coronavirus disease 2019 (COVID-19) in Albania

INTRODUCTION

The study aims to identify potential risk factors for the poor outcome of hospitalized patients with SARS-CoV-2 infection in Albania.

METHODOLOGY

A retrospective observational study on 133 consecutive hospitalized patients at "COVID 1" Hospital, University Hospital Center of Tirana. The study analyzed the correlation between potential risk factors and in-hospital mortality.

RESULTS

The study included 133 patients, 65.4% of the patients were male, age 60.46 ± 13.53 years. The mortality rate resulted in 22.6%. Univariate analysis revealed that early risk factors for mortality included: laboratory alterations on admission, such as lymphocytes count < 1.000/mm3 (OR = 3.30, 95% CI = 1.17-9.33), lactate dehydrogenase > 250 U/L (OR = 12.48, 95% CI = 1.62-95.78) and D dimer > 2 mg/L (OR = 4.72, 95% CI = 1.96-11.36); lung parenchymal involvement > 75% on chest computed tomography on admission (OR = 54.00, 95% CI = 11.89 - 245.11). Cox proportional hazard regression showed that independent risk factors for mortality were lung parenchymal involvement > 75% on chest computed tomography (HR = 8.31, 95%CI: 1.62-42.45) and occurrence of complications during hospital stay (OR = 10.28, 95% CI = 2.02-52.33).

CONCLUSIONS

The risk of poor outcome can be predicted from the early stage of COVID 19 disease, using laboratory data and chest computed tomography. Among patients with COVID 19, lung parenchymal involvement and alterations > 75% on chest computed tomography on admission and laboratory findings, such as lymphocytopenia, and elevated lactate dehydrogenase and D dimer levels, turned out to be early risk factors for in-hospital mortality.

Pyomyositis of piriformis muscle, as a rare cause of deep venous thrombosis

The differential diagnosis of low back pain is long and rarities are under-diagnosed, with problems generally simplified as lumbar vertebral spondylosis or rheumatic conditions. Abscesses of piriform muscle are a particularity worth of evaluating when specific MRI changes are detected, and the condition might be underdiagnosed leading to delays in the treatment. We describe the case of an 18-year-old male with pyomyositis of left piriform muscle, complicated with iliac and femoral vein thrombosis, that responded well to combined antibiotherapy, anticoagulants and drainage.

Primary multiple cerebral hydatid cysts in an immunocompetent, low-risk patient

Cystic echinococcosis is a zoonotic infection that occurs worldwide. Humans are infected through ingestion of parasite eggs in contaminated food, water or through direct contact with infected dogs, which are the definite host. Humans serve accidentally as intermediate host, and occurrences are common in children and young adults. Cystic echinococcosis is endemic in Mediterranean, South American, Middle Eastern, Central Asia, East Africa countries and Australia. The liver is the most frequently involved organ, followed by lungs. Hydatid cysts have been reported only in 2% of cases in the brain. Primary cerebral hydatid disease is a rare entity, but should be considered in the differential diagnosis of cerebral lesions.