Unusual manifestations of brucellosis: a retrospective case series in a tertiary care Greek university hospital

Brucellosis remains a diagnostic puzzle. We retrospectively studied the case notes of 105 patients with brucellosis who were admitted in the Department of Internal Medicine of the University of Patras Hospital, a tertiary care institution serving an extended rural area in western Greece, from 2003 to 2006. Five unusual causes of brucellosis were identified: hepatic, epidural and thyroid abscesses, intrahepatic cholestatic liver disease and pancytopenia. Virtually every human organ and system can be involved in brucellosis, which highlights the need to include brucellosis in the differential diagnosis, especially in endemic areas.

Acute Brucellosis Presenting as Cellulitis

This article does not have an abstract.

Endocarditis due to Salmonella enterica subsp. arizonae in a patient with sickle cell disease: a case report and review of the literature

Human cases due to Salmonella enterica subsp. arizonae are especially rare, but it may affect immunocompromised patients and infants. We present a case of endocarditis in a patient with sickle cell disease and a review of earlier cases caused by this rare human pathogen. The patient was successfully treated with ceftriaxone and ciprofloxacin. There are only few cases of salmonella endocarditis reported in the last six decades and it is the first case of Salmonella enterica subsp. arizonae endocarditis in the literature to the best of our knowledge.

Comparison of Sequential Intravenous/Oral Ciprofloxacin Plus Metronidazole with Intravenous Ceftriaxone Plus Metronidazole for Treatment of Complicated Intra-abdominal Infections

BACKGROUND AND PURPOSE

Intra-abdominal infections are a substantial clinical problem and an important cause of morbidity and death in the hospital. Optimal treatment requires both source control and antibiotic therapy. Sequential intravenous (IV) to oral therapy may improve patient convenience and reduce total health care costs. In this randomized, double-blind trial, the efficacy of sequential IV-to-oral ciprofloxacin plus metronidazole was compared with ceftriaxone plus metronidazole in adult patients with complicated intra-abdominal infections.

METHODS

The trial enrolled 531 patients, who began with IV therapy. Patients who improved clinically were switched to oral therapy on day three or later. The clinical and bacteriological responses four to six weeks after the end of therapy and the safety of the two regimens were assessed. To maintain blinding, the patients received placebo IV in the ciprofloxacin group or placebo orally in the ceftriaxone group. A total of 475 patients (235 ciprofloxacin plus metronidazole, 240 ceftriaxone plus metronidazole) were valid for evaluation of efficacy. All patients were included in the safety analysis.

RESULTS

Of the patients valid for efficacy, 78% of the ciprofloxacin plus metronidazole group and 81% of the ceftriaxone plus metronidazole group were eligible for a switch to oral therapy. The clinical success rates were 98.9% and 96.9%, respectively, which were statistically equivalent. The clinical success rates for all patients, including those on continuous IV therapy, were 90.6% and 87.9%. Source control was achieved in more than 90% of the patients. The bacteriological eradication rates were similar in the two groups. Bacterial complications (e.g., surgical site infections, abscesses) were encountered more often in the ceftriaxone plus metronidazole group.

CONCLUSIONS

Sequential ciprofloxacin plus metronidazole IV-to-oral therapy was statistically equivalent to ceftriaxone plus metronidazole. The switch to oral therapy with ciprofloxacin plus metronidazole was as effective and safe as continued IV therapy in patients able to tolerate enteral feeding.

Prosthetic Valve Endocarditis Caused by Acinetobacter lwoffi

We are reporting a case of recurrent prosthetic-valve endocarditis (PVE) caused by an unusual pathogen. The patient suffered 2 consecutive relapses of Acinetobacter lwoffi bacteremia, although he had completed a full course of treatment with antibiotics to which the microorganism was susceptible. He was finally successfully operated with replacement of the infected aortic valve. Acinetobacter spp are relatively low-grade but potentially virulent pathogens, and endocarditis caused by these species can be fulminant, accompanied by septic complications, and fatal. Although some patients with relapsed PVE may respond to a second course of antibiotics and medical treatment rather than early valve replacement is suggested in A lwoffi PVE, combined antibiotic treatment and early surgical intervention may be considered as the first option in these patients. There are only a few cases of Acinetobacter endocarditis in the literature, and it is the first case reported in Greece to our knowledge.

A rooster's revenge: hepatic abscess caused by a chicken bone

We present the case of a liver abscess caused by a swallowed chicken bone in an elderly man successfully treated with laparotomy. This report illustrates the difficulties of obtaining a preoperative diagnosis. The prolonged time course of the illness, the lack of history of the ingestion of a foreign body, the relatively non-specific symptoms and signs and the non-specific results obtained by conventional radiography resulted in a delayed recognition of this possibly fatal disease. This rare condition should be kept in mind when dealing with cases of hepatic abscess or even septic shock of unknown origin.

Acute transverse myelitis due to Coxsackie virus

The case of a young adult male, who after a short upper respiratory illness presented with fever and alarming progressive neurological deficits, is reported. The diagnostic puzzle and the difficulty in establishing a diagnosis are reported. Acute transverse myelitis is a rare clinical manifestation of Coxsackie virus infection, and very few cases of transverse myelitis caused by serotype B have been reported in the English literature. This is a case report of an unusual acute transverse myelitis caused by Coxsackie B2 infection.

Five-day moxifloxacin therapy compared with 7-day co-amoxiclav therapy for the treatment of acute exacerbation of chronic bronchitis

In this randomized, non-blinded study, the efficacy and safety of a 5-day course of moxifloxacin (one 400 mg tablet daily) was compared with that of co-amoxiclav (one 625 mg tablet every 8h) for 7 days, for the treatment of acute exacerbations of chronic bronchitis (AECB). A total of 162 patients with clear signs of an acute exacerbation of chronic bronchitis were enrolled. Of these, 153 could be studied. Seventy-nine patients were randomized in the moxifloxacin arm and 74 in the co-amoxiclav arm of the study. The primary efficacy parameter was clinical response at 14 days in the evaluable population. A clinical success was classified as resolution or improvement of symptoms. Variables used to assess clinical response included wheeze, cough, dyspnoea, sputum volume, rales and ronchi. The success rate in the moxifloxacin group was 88.6% (70 of 79) and that for co-amoxiclav group was 89.2% (66 of 74). At follow-up (28-35 days post-treatment), the continued clinical cure rates were 90.0% (63 of 70) for moxifloxacin and 89.4% (59 of 66) for co-amoxiclav. No significant differences were detected between the two groups. A total of 78 pathogenic bacteria were isolated from the sputum samples of the patients, with Moraxella catarrhalis, Haemophilus influenzae and Streptococcus pneumoniae being the most frequently isolated pathogens. The eradication rate at 14 days in the valid patients was similar for both groups, 90.9% (20 of 22) for the moxifloxacin group and 90.0% (18 of 20) for the co-amoxiclav group. Both drugs were well tolerated with no differences in the drug-related adverse effects or the patients withdrawing because of an adverse event. These results and the good spectrum of antibacterial activity make moxifloxacin a promising and also safe alternative for the empirical treatment of AECB.

Prevalence of hepatitis B and C virus infection in the general population and selected groups in South-Western Greece

Greece is a country of intermediate endemicity for hepatitis B and low endemecity for hepatitis C with a downward trend during the last years. In the present study we investigated the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in the region of South-Western Greece and tried to identify the most important risk factors of transmission. This is a unique epidemiological study, as it is the first community based study in the general population of Greece, with a methodological approach based on multi-staged random sampling. The prevalence of HBV infection seems to be decreasing with a 22.6% rate of HBV markers and a 2.1% rate of chronic HBV carriers. We found male sex, old age and intrafamiliar exposure as the major independent risk factors of HBV transmission, while sexual contact, absence of condom prophylaxis and living in rural areas seem to have also a significant impact for HBV infection. No relation was found between HBV transmission and working in health care facilities, pre-existing hospital admissions and history of transfusion. The prevalence of anti-bodies to the HCV was found 0.5%, even lower than the rate reported in the Mediterranean region. Parenteral exposure was the main risk factor for the transmission of HCV infection.

Results of a prospective, randomized, double blind comparison of the efficacy and the safety of sequential ciprofloxacin (intravenous/oral)+metronidazole (intravenous/oral) with ceftriaxone (intravenous)+metronidazole (intravenous/oral) for the treatment of intra-abdominal infections

The efficacy and the safety of sequential intravenous/oral (i.v./p.o.) ciprofloxacin (CIPX) plus i.v./p.o. metronidazole (MTR) was compared with i.v. ceftriaxone (CTRX) plus i.v./p.o. MTR in the treatment of complicated intra-abdominal infections. One hundred and forty two patients received study medications. Of these, 135 could be studied. Sixty-nine patients were randomized in the CIPX arm of the study and 66 in the CTRX arm. In the CIPX group 58 patients were switched to oral treatment and 11 patients remained in the intravenous arm. In the CTRX group 57 patients switched to oral MTR continuing i.v. CTRX and 9 patients remained in the i.v. branch. Success rates at the end of treatment in patients who switched to oral were 100% in both the CIPX group and the CTRX group. For validated patients continuing on oral, the success rates at the end of treatment were 63.6 and 33.3% in the CIPX and CTRX groups respectively. Overall success rates at the end of treatment and follow-up in all patients were 94.2% in the CIPX group and 89.4% in the CTRX group. Overall success rates at the end of treatment in patients with proven bacterial infection were 92.9% in the CIPX group and 88.3% in the CTRX group. Duration of hospitalization (days) for studied patients was 22.7+/-8.2 in the CIPX and 19.6+/-14.5 in the CTRX group. There was no statistical difference between the CIPX and CTRX groups in both the intent to treat and in the modified intent to treat populations. Conversion to oral therapy with CIPX/MTR was as effective as continued intravenous therapy with CTRX and oral MTR in those patients able to tolerate oral feeding.

Repeated point prevalence survey of nosocomial infections in a Greek university hospital

Two point prevalence surveys of nosocomial infections (NIs) were carried out in a Greek University hospital on an annual basis in 1998 and 1999. The overall prevalence of NIs was 9.5% and 9.1% in the first and second study, respectively. The average length of stay of patients in the hospital (ALOS) was 7.7 and 9.6 days in these two studies, respectively. Of the 97 NIs detected, the most frequent were lower respiratory tract infections (36%). Urinary tract infections, bloodstream infections, surgical site infections, and gastrointestinal infections were found in 25.8%, 19.6%, 7.2% and 4.1% of patients, respectively. The prevalence of antibiotic usage was 55.6% in 1998 and 54.1% in 1999. Empiric antibiotic therapy prevailed over prophylactic and rational therapies. These percentages are higher than those reported from other countries, emphasizing the need for rational antibiotic usage to decrease pharmacy expenses and discourage the development of resistant microorganisms. A nationwide network of surveillance of NIs in Greece is now being developed using these experiences.

Two episodes of leukoencephalitis associated with recombinant hepatitis B vaccination in a single patient

Cases of central nervous system demyelination have been reported after recombinant hepatitis B vaccination, but no causal link has been clearly demonstrated. We present the first case report involving the occurrence of 2 episodes of leukoencephalitis in a previously healthy patient after vaccination and rechallenge with hepatitis B vaccine.

Intravenous itraconazole followed by oral itraconazole in the treatment of invasive pulmonary aspergillosis in patients with hematologic malignancies, chronic granulomatous disease, or AIDS

The pharmacokinetics, efficacy, and safety of intravenous (iv) itraconazole (2 days at 400 mg/day, 12 days at 200 mg/day), followed by 12 weeks of oral capsules (400 mg/day) were studied in 31 immunocompromised patients with pulmonary invasive aspergillosis. All patients received iv itraconazole (median duration, 14 days), and 26 then received oral itraconazole (median duration, 78.5 days). After receiving iv itraconazole, concentrations increased rapidly, with trough plasma levels > or =250 ng/mL in 91% of patients and in all patients by day 7. Concentrations > or =500 ng/mL were observed in 64% of patients by day 2. Mean trough concentrations after 2 and 14 days were 670 and 850 ng/mL, respectively. Therapeutic levels were maintained after switching to oral capsules. A complete or partial response was seen at the last on-treatment assessment in 15 (48%) of 31 patients, with 6 (19%) showing stable disease. Itraconazole was well tolerated, with no unexpected effects. Overall iv/oral itraconazole was safe and effective in invasive aspergillosis.

A multinational, multicentre, non-blinded, randomized study of moxifloxacin oral tablets compared with co-amoxiclav oral tablets in the treatment of acute exacerbation of chronic bronchitis

The aim of this study was to compare the efficacy and safety of once daily dosing with moxifloxacin (BAY 12-8039) with that of coamoxiclav given three times daily for the treatment of acute exacerbation of chronic bronchitis (AECB). Moxifloxacin (one 400 mg tablet daily) was administered orally for 5 days and co-amoxiclav (three 625 mg tablets daily) was given orally for 7 days. The study was randomized, non-blinded, multinational (12 countries) and multicentre (68 centres). A total of 575 patients, all with clear signs of AECB, were treated, 292 with moxifloxacin and 283 with co-amoxiclav. Of these, 512 patients were evaluable for efficacy (261 in the moxifloxacin group and 251 in the co-amoxiclav group). The primary efficacy parameter was clinical response at 14 days in the evaluable population. A clinical success was classified as resolution or improvement of symptoms. Variables used to assess clinical response included wheeze, cough, dyspnoea, sputum volume, rales and rhonchi. The success rate for moxifloxacin in the evaluable patients was 96.2% and that for co-amoxiclav was 91.6%. The 95% confidence intervals for this difference (0.4%; 8.7%) indicate equivalence in the treatments. Sputum samples were taken from patients and 140 of these contained a pathogen, Haemophilus influenzae being the most frequently isolated. Moraxella catarrhalis and Streptococcus pneumoniae were also commonly isolated pathogens. The eradication rate at 14 days in the evaluable patients was 87.7% in the moxifloxacin group and 89.6% in the coamoxiclav group. Both drugs were well tolerated with no significant differences in the numbers of drug-related adverse events or the numbers of patients withdrawing because of an adverse event. These results and the broad spectrum of antibacterial activity make moxifloxacin a promising and safe alternative to conventional therapy for the empirical treatment of AECB.

Drug-induced acute malaria

The case of an elderly woman with asymptomatic P. malariae infection that acutely reactivated after 45 y of latency following treatment with chlorambucil and methylprednisolone is reported. Only 1 similar case with methotrexate-induced acute malaria has been reported in the English literature thus far.

Serious complications of tuberculous epididymitis

Tuberculous epididymitis is a rare entity associated with minor complications. We present two cases of tuberculous epididymitis associated with serious complications (bilateral psoas abscesses and Addison's disease with psoas abscess). A review of the literature disclosed six additional cases associated with serious complications (Addison's disease, inappropriate antidiuretic hormone secretion, central nervous system involvement) which are discussed and compared to these cases. We conclude that tuberculous epididymitis represents a grave sequela of genital tract involvement and may be associated with serious and even fatal complications.

A randomised, multinational study with sequential therapy comparing ciprofloxacin twice daily and ofloxacin once daily

In a multinational, open, randomised, controlled clinical study, 474 hospitalised patients with moderate or severe infections were treated with sequential regimens of ofloxacin or ciprofloxacin. Ofloxacin 400 mg once daily or ciprofloxacin 200 mg twice daily were given intravenously for at least 3 days followed by oral treatment with ofloxacin 400 mg once daily or ciprofloxacin 500 mg twice daily. Overall cure rates of 86.8% (85.7%) in the ofloxacin group and 89.6 (89.5%) in the ciprofloxacin group were achieved in the intention-to-treat analysis (per protocol analysis). The overall bacteriological response rate (ofloxacin 89.5%, ciprofloxacin 89.0%) was comparable to the clinical cure rate. Both drugs were well tolerated and adverse events were rarely observed. It is concluded that ofloxacin and ciprofloxacin can be used successfully in the treatment of hospitalised patients with aerobic gram-positive and gram-negative infections. Ofloxacin has the advantage of a once-daily regimen, compared to the twice-daily regimen with ciprofloxacin.

Intramural gastric actinomycosis

We report a case of intramural gastric actinomycosis and review the features of the additional 16 cases of this uncommon infection reported in the literature. The patient had gastrointestinal symptoms, weight loss, and fever after gastric operation. At laparotomy, an infiltrating gastric tumor-like lesion was found. Histology revealed actinomycosis, and the patient was successfully treated with oral penicillin. Because of its rarity, intramural actinomycosis is an entity overlooked by most surgeons. Reporting of such cases may help increase the awareness of this important and curable disease.

Differences in adherence to buccal epithelial cells, in phagocytosis and in killing by neutrophils between human and non-human strains of Candida albicans

The adherence of strains of Candida albicans to buccal epithelial cells as well as the phagocytosis of these organisms by human polymorphonuclear leucocytes (PMNL) was studied. The strains of C. albicans were obtained from patients' urine. from bird faeces and from soil. The strains of C. albicans obtained from patients and the environment displayed greater adhering ability (23.8 +/- 6.4 and 27.5 +/- 5.2 respectively) than the avian strains (14.4 +/- 2.2) (P < 0.01). Strains obtained from the environment were resistant to phagocytosis (81.6 +/- 0.2 organisms ingested per 200 PMNL) and killing (8.4 +/- 2.6%) by PMNL as compared to human and avian strains (P < 0.01). These observations indicate that environmental strains of C. albicans may be more virulent for human beings.

Effects of propofol and thiopentone on polymorphonuclear leukocyte functions in vitro

Anesthetic agents may impair host defense mechanisms including polymorphonuclear leukocyte (PMNL) function. We have studied the effects of thiopentone and propofol in low (thiopentone 10 mg/L, propofol 2 mg/l) and high (thiopentone 40 mg/L, propofol 6 mg/L) clinically relevant concentrations on PMNL adherence, chemotaxis, phagocytosis and killing in vitro. The results demonstrated that thiopentone in both concentrations significantly decreases all PMNL functions tested and had a direct influence on the PMNLs in terms of their chemotactic response. In contrast, propofol decreases significantly only PMNL chemotaxis but not adherence, phagocytosis and killing. The effect of propofol was not attributable to the lipid carrier vehicle, as Intralipid with same formulation had no effect on PMNL function. We conclude that propofol is a relatively safe agent from the viewpoint of PMNL function in vitro, which may be of potential clinical benefit.

Successful treatment of thoracic actinomycosis with ceftriaxone

We report the case of a 38-year-old woman who had pulmonary actinomycosis that involved the pleura and the pectoral muscles. The patient was initially treated with intravenous ceftriaxone once a day on an outpatient basis. After 3 weeks of treatment, a computed tomogram showed resolution of the initial findings. This result suggests that ceftriaxone may be an effective and convenient therapeutic agent for the initial parenteral treatment of actinomycosis.

False positive widal reaction in high-titer disseminated BCG infection

False-positive Widal reactions following certain non-typhoid Salmonella infections may occur commonly. The case of a patient who developed miliary tuberculosis secondary to intravesical bacillus Calmette-Guérin (BCG) immunotherapy for bladder carcinoma is described. Very high titers of typhoid and paratyphoid agglutinins were obtained with the Widal test; these titers returned to normal after successful anti-tuberculous treatment. This case of high-titer, false-positive Salmonella typhi and Salmonella paratyphi A and B reactions to BCG infection occurred in an area non-endemic for typhoid or paratyphoid fever.

Non-tropical pyomyositis in adults: report of four cases and literature review

Four cases of non-tropical pyomyositis in adults are presented and 72 cases reported in the literature are reviewed. The diagnosis is often overlooked or delayed because most physicians are not familiar with the entity. Local signs of inflammation fever, leukocytosis and an elevated erythrocyte sedimentation rate are common features. Staphylococcus aureus is the most common pathogen and the thigh muscles are the most common site involved. Computerized tomography is used to establish the diagnosis and surgical incision and drainage in combination with antibiotic therapy is successful in the majority of the cases.