Non-bacteremia liver abscess caused by Burkholderia pseudomallei from a tertiary teaching hospital in Malaysia: a case report and literature review

Melioidosis is endemic in Southeast Asia, including Malaysia. Liver abscess is not uncommon in melioidosis, but it is usually associated with bacteremia. We presented a case of a 55-year-old gentleman with underlying end-stage renal failure who presented with non-specific abdominal pain for three months. Initial blood investigations showed leukocytosis and increased C-reactive protein. Computed tomography (CT) of the abdomen revealed multiple hypodense lesions in the liver and spleen. The culture of the liver specimen obtained through the ultrasound-guided isolated Burkholderia pseudomallei. He was given an adjusted dose of intravenous ceftazidime due to underlying renal failure. Melioidosis serology also returned positive for IgM with titer >1:1280. His blood cultures were reported negative three times. Despite on antibiotics for five weeks, there was no significant improvement of the liver abscesses was observed. He was unfortunately infected with the SARS-CoV-2 virus during his admission and passed away due to severe COVID-19 pneumonia.

The risk factors for complications and survival outcomes of Klebsiella pneumoniae Bacteraemia in Hospital Canselor Tuanku Muhriz Universiti Kebangsaan Malaysia

INTRODUCTION

Mortality of Klebsiella pneumoniae (K. pneumoniae) bacteraemia was reported to be on the rise globally. The 30-day mortality rate of K. pneumoniae bacteraemia ranges from 16% to 55% in Beijing, Shanghai, and Taiwan. However, there is a lack of research on the survival outcomes of K. pneumoniae bacteraemia in Malaysia. The objectives of this study were to determine the poor prognostic factors and predictors of 14-day in-hospital mortality from K. pneumoniae bacteraemia.

METHODS

This was a retrospective cohort study of patients with K. pneumoniae bacteraemia in Hospital Canselor Tuanku Muhriz Universiti Kebangsaan Malaysia (HCTM). We included adult patients with blood cultures positive for K. pneumoniae between 1 January 2016 and 31 December 2019. Those with polymicrobial bacteraemia were excluded. Medical records were reviewed to obtain the sociodemographic data, gender, underlying comorbidities, invasive procedures at presentation, sources of bacteraemia, and whether appropriate empirical and definitive antibiotics was given on time. Data regarding complications of K. pneumoniae bacteraemia, including liver abscess, endopthalmitis, septic shock, Quick Pitt (qPitt) bacteraemia score defined as hypothermia, hypotension, respiratory failure, cardiac arrest, and altered mental status and stay in intensive care unit (ICU) were also recorded. The main outcome measure used was the survival in 14 days. Summary of statistical analysis was done.

RESULTS

A total of 260 patients with K. pneumoniae bacteraemia were included. All patients received appropriate empirical and definitive antibiotics within 24 h of the time that the sample for index blood cultures was obtained. Respiratory infection, septic shock, qPitt bacteraemia score ≥2, solid organ malignancy, stay in ICU, central venous line insertion at presentation, urinary catheterisation at presentation, and in-patient mechanical ventilation were identified as independent predictors of mortality in K. pneumoniae bacteraemia. The rate of complications such as liver abscess, endophthalmitis, ICU admission, and septic shock was not significantly different between survivors and non-survivors. The 14-day in-hospital mortality rate was 12.3%. The median length of hospitalisation was 11 days (IQR 6 - 19) . The predictors of poor prognosis for 14 days in-hospital mortality for K. pneumoniae bacteraemia were as follows: qPitt bacteraemia score ≥2, central venous line insertion, indwelling urinary catheter at presentation, and in-patient mechanical ventilation. Timing from K. pneumoniae bacteraemia event to death among those qPitt bacteraemia scores ≥2 was only for 9 days or less.

CONCLUSIONS

The 14-day in-hospital mortality of patients with K. pneumoniae bacteraemia in our setting was low. The qPitt bacteraemia score ≥2 was the strongest predictor of poor prognosis for 14-day in-hospital mortality in patients with K. pneumoniae bacteraemia. The qPitt bacteraemia score should be proposed to be used as a bedside screening tool for gram negative bacteraemia in our daily clinical practice, which is also useful for predicting mortality in critically ill patients.

POS0723 HERPES ZOSTER IN A MULTI-ETHNIC SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) COHORT: CLINICAL FEATURES AND RISK FACTORS

Background:

Systemic Lupus Erythematosus (SLE) patients are at risk of Herpes Zoster (HZ) infection due to the underlying immunosuppressed state. The reported incidence of HZ in SLE is 6 to 10-times higher than the general population.

Objectives:

To determine the clinical characteristics of SLE patients who develop Herpes Zoster (HZ) infection and their associated risk factors.

Methods:

Medical records review was performed on consecutive SLE patients in Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from 2018 until 2019. Previous history of HZ and their demographic characteristics, clinical and medications used at the time of infection were recorded. Univariate and multivariate analyses were performed to compare the clinical and treatment characteristics between SLE patients with history of HZ and patients who had never had experienced HZ.

Results:

A total of 229 patients with predominantly Malay patients (n=123, 53.7%), followed by Chinese (n=90, 39.3%) and others (n=16, 7.0%) were included. A total of 37 patients had history of HZ (16.2%). Their mean age during HZ episode was 34.4 ± 13.8 years and their SLE disease duration was 68.7 ±57.1 months. More than half of them (n=21, 56.8%) developed HZ when the SLE disease was active with the mean dose of prednisolone at the time of infection was 20.7 ± 9.2 mg daily. A total of 21 HZ patients (56.8%) had ever received cyclophosphamide with the median interval of the last infusion was 6 (0.2-84) months. Almost half of the HZ patients (n=18, 48.6%) developed the infection while on cyclosporine A. Meanwhile, 4 (10.8%) were on azathioprine and mycophenolate mofetil respectively. Chinese patients tend to have HZ as compared to other ethnics (27% vs 41.7%), p=0.07. HZ occurred in a higher proportion among male patients (29%) as compared to female patients (14.1%), p=0.05. The use of azathioprine (10.8% vs 55.2%, p<0.01) and mycophenolate mofetil (10.8% vs 31.8%, p=0.009) were less associated with HZ. On the other hand, the use of cyclosporine A (48.6% vs 32.3%, p=0.05) and prednisolone ≥ 60mg daily (44.4% vs 28%, p=0.04) were associated with HZ. Higher HZ patients had hematological manifestation (81.1% vs 62.5%, p=0.04) and positive lupus anticoagulant (LA), 32.4% vs 14.6%, p=0.02. A forward logistic regression which included all factors with p<0.1 in the univariate analyses revealed that the use of prednisolone ≥ 60mg daily and hematological manifestation were the independent predictors of HZ with OR= 2.28 (95% C.I = 1.01-5.17), p=0.049 and OR= 2.78 (95% C.I = 1.09-7.04), p=0.03 respectively. The use of azathioprine was associated with a lower risk of HZ with OR 0.08 (95% C. I= 0.03-0.25), p=<0.01.

Conclusion:

Our study demonstrated the possible influence of male gender, Chinese ethnicity and disease characteristics such as hematological manifestation and lupus anticoagulant positivity with the occurrence of HZ. In addition, the use high dose oral prednisolone ≥ 60mg daily was the independent predictor of HZ while on the other hand, the use of azathioprine was associated with a lower risk of developing HZ as compared to other immunosuppressive agents. Further larger studies are needed to confirm these associations.

References:

[1]Chen D, Li H, Xie J, Zhan Z, Liang L, Yang X. Herpes zoster in patients with systemic lupus erythematosus: Clinical features, complications and risk factors. Exp Ther Med. 2017;14(6):6222-6228.

Disclosure of Interests:

None declared

Novel technique of sutureless glueless scleral fixated intraocular lens (SFIOL)

Purpose:

To report results of a novel technique for sutureless, glueless intrascleral fixation of three-piece posterior chamber intraocular lens (IOL) using 26-G needle for management of aphakia.

Methods:

In this prospective series, 30 eyes of 20 patients with aphakia, subluxated IOL, or crystalline lens were included. 26-G-needle-guided intrascleral fixation of three-piece posterior chamber IOL was performed according to the described technique. The patients were evaluated on day 2, 1 week, 6 weeks, and 3 months postoperatively for change in best-corrected visual acuity (BCVA), intraocular pressure (IOP), IOL centration, and any other complications. The postoperative tilt of the IOL was indirectly measured by determining the lenticular astigmatism which in turn was calculated by the difference between net corneal astigmatism and refractive astigmatism. Paired t-test was used to determine the significance of any association between the preoperative and postoperative BCVA and IOP. P < 0.05 was considered significant.

Results:

Of 30 eyes (n = 30 patients), 18 were surgical aphakia, 6 traumatic aphakia, 5 subluxated IOL, and 1 ectopia lentis (Marfan syndrome). The mean preoperative BCVA was 1.37 ± 0.37 (logMAR) and postoperative BCVA at 3 months was 0.37 ± 0.29 (logMAR). A significant improvement in the mean BCVA (P < 0.05) was observed after the procedure. The mean IOP preoperatively was 13.33 ± 4.18 and postoperatively at 3 months was 12.82 ± 3.97 (P > 0.05), which was not significant. None of the eyes developed any intraoperative and postoperative complications. The IOLs had appropriate centration and stability.

Conclusion:

We have developed this new technique for intrascleral IOL fixation which is quite simple, cost-effective, minimally invasive, neither requires glue nor suture and gives consistent outcome.

Switching from sulphonylurea to a sodium-glucose cotransporter2 inhibitor in the fasting month of Ramadan is associated with a reduction in hypoglycaemia

The aim of the present study was to assess the hypoglycaemia risk and safety of dapagliflozin compared with sulphonylurea during the fasting month of Ramadan. In this 12-week, randomized, open-label, two-arm parallel group study, 110 patients with type 2 diabetes who were receiving sulphonylurea and metformin were randomized either to receive 10 mg (n = 58) of dapagliflozin daily or to continue receiving sulphonylurea (n = 52). The primary outcome was to compare the effects of dapagliflozin and sulphonylurea on the proportions of patients with at least one episode of hypoglycaemia during Ramadan, as well as to assess the safety of dapagliflozin when used to treat patients observing Ramadan. A lower proportion of patients had reported or documented hypoglycaemia in the dapagliflozin group than in the sulphonylurea group: 4 (6.9%) versus 15 (28.8%); p = 0.002. The relative risk of any reported or documented hypoglycaemia in the 4th week of Ramadan was significantly lower in the dapagliflozin group: RR=0.24, 95%CI: 0.09, 0.68; p=0.002. No significance differences were observed between the two groups regarding postural hypotension (13.8 vs 3.8%; p = 0.210) or urinary tract infections (10.3 vs 3.8%; p = 0.277). In conclusion, fewer patients exhibited hypoglycaemia in the dapagliflozin group than in the sulphonylurea group.

[Clinical studies on zinc oxide ointment replacing boric acid and zinc oxide ointment (JP8)]

A boric acid and zinc oxide ointment (J.P. VIII) is an unique preparation in Japan, which consist of boric acid (5%), zinc oxide (10%), vegetable oil (usually soybean oil or sesame oil) and yellow wax. The ointment is widely used in the area of Hokkaido, because not only of the customary prescription but also of the characteristic clinical efficiency. However, boric acid has been recognized to be harmful in these days. Therefore, a zinc oxide ointment consisting 10% zinc oxide, soybean oil and white beeswax was tentatively made and evaluated. The zinc oxide ointment presented the same consistency as the boric acid and zinc oxide ointment, measured with penetrometer. The clinical efficiency was also confirmed on six patients with chronic eczema and seven patients with psoriasis vulgaris. The effect on wound healing of the donor site of skin graft was as good as the previous preparation.