肾移植术后复发性亚急性感染性心内膜炎一例

正1病例资料患者男性,52岁,因间断发热4个月余于2015年8月入院。4个月前患者血透时出现发热,体温最高38.5℃,伴咳嗽、咳白痰,予以静脉滴注哌拉西林他唑巴坦钠后体温下降,但仍波动于37.0℃~37.6℃。超声心动图检查(Echo)提示主动脉瓣赘生物生成可能,3次血培养均示杰氏棒状杆菌     

肾移植术后感染性心内膜炎成功救治一例

患者男,66岁,因活动后喘憋5年,不能平卧伴体重下降3个月入院.患者5年前开始出现劳累后喘憋症状,休息后可缓解,未治疗.5个月因"感冒",曾输液治疗(药名不详),无好转,喘憋症状加重,出现夜间阵发性呼吸困难和端坐呼吸,收入我院心脏中心.近3个月来体重减轻1O kg.     

Actinobacillus actinomycetemcomitans endocarditis in a patient with a prosthetic aortic valve

Summary Bacterial endocarditis caused by Actinobacillus actinomycetemcomitans is a rare disease. A 48-year-old man who had a Starr-Edwards aortic valve prosthesis inserted in 1972 was admitted for evaluation of confusion, headaches, anorexia, weight loss, diarrhea and weakness. Six blood cultures yielded gram-negative organisms which were subsequently identified as A. actinomycetemcomitans. Treatment with ampicillin and gentamicin resulted in cure which has been maintained after an observation period of eleven months. This represents the second report of A. actinomycetemcomitans endocarditis in a patient with a prosthetic valve.

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Endokarditis infolge Actinobacillus actinomycetemcomitans bei einem Patienten mit Aortenklappenersatz

Zusammenfassung Bakterielle Endokarditis durch Befall mit Actinobacillus actinomycetemcomitans ist eine seltene Erkrankung. Ein 48jähriger Mann, dem 1972 eine künstliche Aortenklappe vom Typ Starr-Edwards eingesetzt worden war, wurde zur klinischen Beurteilung eines aus Verwirrung, Kopfschmerzen, Anorexie, Gewichtsverlust, Diarrhoe und Schwäche bestehenden Syndroms stationär aufgenommen. Sechs Blutkulturen wiesen gramnegative Organismen aus, die nachfolgend als A. actinomycetemcomitans identifiziert wurden. Eine Behandlung mit Ampicillin und Gentamycin führte zur Heilung, die nach einer Beobachtungsdauer von elf Monaten anhielt. Dies ist der zweite Bericht über Endokarditis infolge A. actinomycetemcomitans bei einem Patienten mit Klappenersatz.

     

Eikenella corrodens prosthetic valve endocarditis in a patient with ulcerative colitis

A 33-y-old male with ulcerative colitis developed prosthetic valve endocarditis (PVE) caused by Eikenella corrodens. The outcome of conservative treatment was successful. Only 2 cases of E. corrodens PVE were found in a survey of the English-language medical literature. In contrast to previous data indicating that eikenella infections usually derive from the oral cavity, our patient most likely acquired the infection by colonoscopy and mucosal biopsies, which were performed a few days before onset of the disease.     

Listeria monocytogenes endocarditis in a patient with an aortic prosthetic valve

Patients with prosthetic cardiac valves have an increased risk of developing bacterial endocarditis. The causative micro-organism in bacterial endocarditis may be a guide to the portal of entry. In this case report, we describe a patient with a prosthetic cardiac valve who suffered from recurrent endocarditis with different micro-organisms from the gastrointestinal tract.     

Successful allogeneic blood stem cell transplantation for aplastic anemia in a patient with renal insufficiency requiring dialysis

A 27-year-old man with aplastic anemia and renal insufficiency requiring dialysis underwent allogeneic PBSCT. The preparative regimen consisted of melphalan, ATG and TLI. GVHD prophylaxis consisted of cyclosporine and prednisolone. He was dialyzed prior to administration of melphalan and at 24 and 72 h after it. Otherwise, the dialysis schedule was unchanged, at three times a week. Engraftment was rapid. Regimen-related toxicity was minimal. Pharmacokinetic parameters of melphalan were not significantly altered with its plasma half-life 1.5 h. Patients with renal failure can receive allogeneic HSCT, and a combination of melphalan, ATG and TLI may serve as an alternative to CY and ATG.     

52-year old patient with skin discoloration

Zusammenfassung Das antiarrhythmisch wirksame Medikament Amiodaron kann nach l?ngerer Anwendung dosisabh?ngig zu einer Dyschromie an den lichtexponierten Arealen der Haut führen. Die Pigmentgranulae im oberen und mittleren Korium sind Komplexe aus Phaeomelanin, Lipochromen und unbekannten jodhaltigen Amiodaronmetaboliten. Eine aggravierende Funktion kommt UVA- und UVB-Licht zu. Mit einer spontanen Abblassung ist erst nach mehreren Jahren zu rechnen. Meidung von UV-Licht, topischer Lichtschutz und die begleitende Gabe von 300 mg Pyridoxin/Tag werden empfohlen. Da die Ablagerung der Pigmentgranulae im Korium sehr sensitiv durch eine Hautbiopsie erfasst werden kann, empfehlen wir bei Vorliegen einer therapeutischen Alternative zus?tzlich eine histologische Untersuchung (Masson-Fontana-F?rbung) eines Hautbiopsates aus einem lichtexponierten Areal.     

Treatment of complicated prosthetic aortic valve endocarditis with annular abscess formation by homograft aortic root replacement

The outcome of 30 consecutive patients with active aortic prosthetic valve endocarditis and root abscesses treated by the technique of homograft aortic root replacement with reimplantation of the coronary arteries is detailed. The principles of this technique are the removal of all abscesses and infected areas likely to drain into the infected mediastinum, excision of infected tissues down to healthy noninfected tissue and replacement with an antibiotic-impregnated homograft aortic root. All patients had evidence of progressive cardiac failure and ongoing sepsis. Mean patient age (+/- SD) at the time of operation was 42 +/- 18 years. The mean number of previous aortic valve replacements per patient was 1.6 +/- 0.7; 14 patients (47%) had undergone greater than or equal to 2 previous replacements. At operation, aortic root abscesses were found in all patients; abscess extension to adjacent structures and partial valve dehiscence had occurred in 23. In-hospital death occurred in 9 (30%) of the 30 patients. The 21 hospital survivors have been followed up for a mean of 66 +/- 42 months (range 9 to 144). Overall, 17 (81%) of the 21 hospital survivors have remained free of major adverse events (recurrence of endocarditis, need for reoperation or death). The results of our study suggest that homograft aortic root replacement should be considered favorably in the treatment of patients with aortic prosthetic valve endocarditis and root abscesses.     

Encephalitis in a renal transplantation patient

The patient was a 55 year-old-woman with chronic renal failure due to idiopathic mesngial deposition of Ig A. She received a second allograft of a kidney from a cadaver. Results of a preoperative serologic Ig G tests for EBV and CMV were positive. She was given triple-drug immunosuppressive therapy, consisting of cyclosporine,azathioprine, and steroids. Seven years later, azathioprine was changed to mycophenolate mofetil. One year later, she was admitted to the hospital with a three to four week history of vertigo (which did not improve after sulpiride was administrated) and an influenza-like syndrome. A CT scan of the brain appeared normal, so paroxysmal positional vertigo was the diagnosis. Two weeks after admission to the hospital, the patient reported visual hallucinations and impairment of consciousness. Results of laboratory tests were leukocyte increase (polymorphonuclear leukocytes), anemia, hyponatremia and renal failure. Chest radiography, brain CT, and electroencephalography revealed no pathologic signs. The CSF examination revealed 300 cells/ml (79% PMNL), glucose 63 mg/dl, protein 45 mg/dl. Six hours later the treatment was initiated with ampicillin, ceftriaxone and ganciclovir iv, she experienced seizures that affected the left side of her body, but without interictal recovery. The patient required intubation and mechanical ventilation in the intensive care unit. An MRI of the brain images, revealed high signal-intensity regions indicating lesions on the bulb, protuberance, mesencephalon, left thalamus and parenchyma adjacent to the corpus callosum (fig. 1). Six days later, the patient partially recovered consciousness, and she had not neurologic sequelae. Intubation was terminated. As soon as PCR revealed EBV DNA in CSF samples, the treatment with ceftriaxone and ampicillin was discontinued. Treatment with ganciclovir was maintained for 8 weeks (4 weeks with iv and another 4 weeks with oral treatment). On day 35, the examination of a specimen of CSF revealed: glucose 46, protein 78, 15 cells/ml (100% lymphocytes). The patient went home on day 55 after admission to our hospital. She regained her normal neurologic function. Three weeks later MRI, showed reduction of the size of the lesions and the lesions on the brain stem had disappeared.     

A patient with progressive multiple myeloma treated successfully with arsenic trioxide after allogeneic bone marrow transplantation

Multiple myeloma (MM) is an incurable progressive disease. Many therapeutic options are available to delay progression, including autologous and allogeneic bone marrow transplantation. At advanced stages, MM is often refractory to treatment. We report a heavily pretreated patient with graft-versus-host disease after bone marrow transplantations, treated at a terminal stage with a modified protocol for arsenic trioxide (ATO). This patient with poor clinical status tolerated the treatment very well. He had a remarkable clinical response and achieved complete remission. The mechanisms of ATO are presented and the potential role of ATO for MM is discussed.     

Methicillin-resistant Staphylococcus aureus prosthetic aortic valve endocarditis with paravalvular abscess treated with daptomycin

Prosthetic valves have been used extensively for severe cardiac valvular dysfunction for the past 3 decades. Prosthetic cardiac valves may be infected with organisms causing bacteremia, particularly gram-positive cocci. Staphylococcus epidermidis (coagulase negative staphylococci) and Staphylococcus aureus , both methicillin-susceptible S. aureus and methicillin-resistant S. aureus (MRSA) strains, are the most frequent pathogens causing prosthetic valve endocarditis (PVE). Vancomycin has been the cornerstone of therapy for serious MRSA infections including bacteremia and endocarditis. Clinicians have noted that MRSA bacteremias treated with vancomycin often fail to clear even with prolonged therapy. Persistent or prolonged MRSA bacteremia unresponsive to vancomycin therapy has led to the treatment of these infections by other agents, that is, quinupristin, dalfopristin, linezolid, or daptomycin. These antibiotics have been found particularly useful in treating MRSA bacteremias unresponsive to vancomycin therapy. We report a case of a patient who presented with MRSA PVE complicated by perivalvular aortic abscess with persistent MRSA bacteremia unresponsive to vancomycin therapy. The patient's MRSA bacteremia was cleared with daptomycin therapy (6 mg/kg/d). Because the patient refused surgery, daptomycin therapy was continued in hopes of curing the endocarditis and sterilizing the perivalvular aortic abscess. Transesophageal echocardiogram revealed a decrease in abscess in the aortic perivalvular abscess after 1 week of daptomycin therapy. The patient made an uneventful recovery. The cure of PVE and perivalvular abscesses usually requires removal of the prosthetic device and abscess drainage. In this case, in which surgery was not an option, medical therapy of PVE and a decrease in size of the aortic perivalvular abscess were accomplished with daptomycin therapy. Daptomycin is an alternative to vancomycin therapy in patients with prolonged or persistent MRSA bacteremia secondary to endocarditis or abscess.     

Full-term pregnancy after allogeneic transplantation for leukemia in a patient with oligomenorrhea

A 21-year-old patient had a normal full-term delivery 3 1/2 years after bone marrow transplantation for acute lymphoblastic leukemia. She had oligomenorrhea both before and after transplantation. This case illustrates that normal pregnancy is possible after regimens incorporating total body irradiation and that patients should be counselled accordingly.     

Early tumor regression following severe lung injury after allogeneic stem cell transplantation in a patient with renal cell carcinoma

We describe a 65-year-old man who had repeated lung injuries after reduced-intensity allogeneic stem cell transplantation (RIST) for renal cell carcinoma. Severe pneumonitis developed twice at the time of neutrophil recovery and acute graft-versus-host disease. Both episodes were successfully treated with steroid pulse therapy. Metastases regressed after the first episode and were stable during these lung disorders, but he died of tumor progression 6 months after RIST. This case suggests that certain local inflammatory reactions may be associated with an anti-tumor effect.     

肾移植后复发的单克隆IgG沉积肾小球肾炎

中年男性,6年前发现肾病综合征,虽经治疗但肾功能仍进行性恶化;自体肾肾活检符合单克隆IgG沉积肾小球肾炎.发病后3年因慢性肾功能不全行肾移植术,肾移植术后1年蛋白尿再现,行移植肾活检证实单克隆IgG沉积肾小球肾炎复发.