Ocular necrotizing fasciitis due to Pseudomonas aeruginosa in a non-neutropenic patient

Eyelid necrosis is a very rare disease, usually secondary to trauma or infections. Pseudomonas aeruginosa (PA) eyelid necrosis remains principally a clinical diagnosis and it is often missed early in its presentation because of the difficulty in differentiating it from more common soft tissue infections. However, when the diagnosis is made we must act quickly due to the fatal evolution if not handled properly. We present the case of a non-neutropenic 53-year-old male patient with a history of alcoholism, smoking habit and lung cancer under chemotherapy treatment who developed ocular necrotizing fasciitis due to PA with perforation of his left eye and severe bilateral sclera ischemia despite intensive antibiotic treatment and surgical debridement.     

Correction to: Musculoskeletal infections caused by Aerococcus urinae: a case-based review

Clinical Rheumatology - The presentation of the Table 1 of the original version of this article was incorrectly published. The Table is now presented correctly in this article.     

Rehabilitation Program in Adult Congenital Heart Disease Patients with Pulmonary Hypertension

Introduction. It is commonly believed that physical activity may have a negative impact on pulmonary hypertension patients. The object of this study is to determine the tolerability of a directed exercise program in congenital heart disease patients with pulmonary hypertension. Methods. Eight congenital heart disease patients with pulmonary hypertension were studied and followed up during a 1-year period. Four of them were enrolled in a 3-month rehabilitation program. Results. No significant changes in analytical data, hand and leg strength, or quality of life were seen at the end of the training program in rehabilitation and nonrehabilitation patients. However, patients in the rehabilitation group improved 6 minutes' walk test minimum hemoglobin oxygen saturation and functional class after ending the training program without having adverse events such as progression of symptoms or heart failure. Conclusions. Cardiopulmonary rehabilitation appears to be a safe intervention in patients with congenital heart disease and pulmonary hypertension.     

Esophageal varices hemorrhage. Endoscopic treatment

The patient with bleeding esophageal varices represents always a challenge to the medical team carrying a high mortality in spite of advances in pharmacologic and endoscopic treatments, notwithstanding that bleeding is just one added complication in the setting of the ailments of portal hypertension. Sclerotherapy, once the treatment of choice, has been displaced in recent year by variceal ligature, with less morbidity and equal success rate, both of them being technically simple. In the same way, variceal ligature has displaced sclerotherapy as treatment for secondary prophylaxis, with less complications and less sessions needed for variceal erradication and bleeding prevention. On the other hand, sclerotherapy is not indicated for patients with large varices, while ligature competes with pharmacologic treatment, some people suggesting the superiority of ligature because of better patient compliance, although probably the best option would be a combination of both. Thus, endoscopic treatment has an important role in this clinical situation, both for diagnosis as for management of active bleeding and primary prophylaxis.     

Cor Triatriatum Dexter versus Prominent Eustachian Valve in an Adult Congenital Heart Disease Patient

An eustachian valve (EV) remnant, if present, is usually noted by the presence of a thin ridge or a crescent‐shaped fold of endocardium arising from the anterior rim of the inferior vena cava orifice due to the persistence of the right sinus venosus valve. Though the embryologic explanation of cor triatriatum dexter (CTD) is the same as that of the normal formation of the EV—lack of regression of the right sinus venosus valve—it is usually called CTD or divided right atrium when there are attachments on the atrial septum giving the appearance of a divided atrium. However, it's called prominent eustachian valve when the right sinus venosus valve has partly regressed, with no remaining septal attachments and without the appearance of a divided atrium. We present the case of an adult patient with an atrial septal defect with a high insertion of a giant EV, which mimics the echocardiographic appearance of divided right atrium.     

Subclinical Hypothyroidism in Grown-Up Congenital Heart Disease Patients

Subclinical hypothyroidism usually is asymptomatic, but it can be associated with various adverse cardiologic outcomes. With the objective of gaining insight into the role of thyroid-stimulating hormone (TSH) in congenital heart abnormalities, this study measured serum TSH concentrations in different subtypes of grown-up congenital heart disease (GUCHD) patients. Serum TSH (reference range, 0.34–5.6 mIU/L), creatinine, cholesterol, C-reactive protein (CRP), N-terminal proB-type natriuretic peptide (NT-pro-BNP), and 24-h proteinuria were measured in 249 GUCHD patients. Of 24 GUCHD patients (9.6 %) with a TSH level higher than 5.6 mUI/L, nine were cyanotic (37.5 %) and seven (29.1 %) had Down syndrome. The GUCHD patients with serum TSH exceeding 5.6 mIU/L had a significantly higher level of serum NT-pro-BNP (195.1 [0.28; 5,280.3] vs 57.6 [0.00; 929.8]; p = 0.001) and CRP (0.30 [0.06; 1.87] vs 0.16 [0.00; 1.40]; p = 0.011] than those with a TSH level of 5.6 mIU/L or lower. No significant differences were found in serum creatinine, lipids, or 24-h proteinuria between the two groups. The T4 concentrations in the GUCHD patients with TSH exceeding 5.6 mIU/L were within the normal range (0.89 ± 0.23 ng/dL). In the multivariate analysis, cyanosis (odds ratio [OR], 6,399; 95 % confidence interval [CI] 2,296–17,830; p < 0.001), Down syndrome (OR, 6,208; 95 % CI, 1,963–19,636; p = 0.002), and NT-pro-BNP concentrations (OR, 1,001; 95 % CI, 1,000–1,002; p < 0.026) proved to be risk factors for TSH levels higher than 5.6 mIU/L. Because subclinical hypothyroidism entails a cardiovascular risk, the authors postulate that TSH screening should be included in the routine follow-up evaluation of GUCHD patients with cyanosis or Down syndrome.     

Efficacy of Albaconazole against Candida albicans in a Vaginitis Model

The efficacy of albaconazole (ABC) was evaluated using a murine model of vaginal Candida albicans infection. Both ABC and fluconazole (FLC) were effective in reducing the fungal load from vaginas of infected mice; however, ABC demonstrated encouraging activities against an FLC-resistant strain, with trends toward superiority over FLC in some treatment groups.Vulvovaginal candidosis is a common infection among healthy women and is caused by members of the genus Candida, predominately Candida albicans (12). Current treatments for Candida vulvovaginitis include a wide range of intravaginal azole preparations, usually administered over several days. No evidence exists to suggest that any one formulation results in a better cure rate; overall cure rates for topical azoles range from 80% to 90% (13). Recent reports on the comparative efficacies of local versus oral treatments of uncomplicated vulvovaginal candidosis found no significant difference between either treatment modality (8); however, many patients prefer the convenience of oral administration. Oral fluconazole (FLC), a triazole, with its marked in vitro activity against Candida species, clinical efficacy, and ease of administration, is a convenient alternative to topical therapy in a single-dose regimen (11, 14) and is the most-prescribed treatment for vulvovaginal candidosis.Albaconazole (ABC) (formerly UR-9825) is also a triazole antifungal molecule, under development by Stiefel Laboratories, Inc. (Coral Gables, FL). ABC has potent and broad-spectrum antifungal activity, with good in vitro activity against yeast (4, 6, 9), dermatophytes (3), and some filamentous and opportunistic fungi, such as Aspergillus spp., Paecilomyces spp., and Chaetomium spp. (2). ABC also has activity against the protozoon Trypanosoma cruzi (15).In the present study, we compared the effectiveness of ABC and FLC for the treatment of experimental C. albicans vaginitis caused by an FLC-resistant isolate.C. albicans isolate 03-2718 has been used previously in our laboratory for studies of vaginal candidosis (5). The 48-h MICs of ABC and FLC were 0.5 μg/ml and >64 μg/ml, respectively. This indicates that in vitro, the isolate is resistant to FLC (7). The yeast was grown in sterile bottles, each containing 100 ml of RPMI-1640 with l-glutamine (Hardy Diagnostics, Santa Maria, CA), and incubated for 24 h at 35°C on a gyratory shaker. C. albicans was harvested by centrifugation, and the cells were counted in a hemocytometer. Quantitative cultures by serial dilution were used to confirm the inoculum size.Five-week-old BALB/c mice (weight, 18 g) were purchased from Harlan Mexico. A total of 10 mice were randomly assigned to each treatment or control group. Mice were housed five per cage and were provided food and water ad libitum. All animal research procedures were approved by the ethics committee of our university. Care, maintenance, and handling of the animals were in accordance with the Mexican government license conditions for animal experimentation. Two confirmatory animal studies were performed.A previously described model of vaginal candidosis was utilized (1). Three days prior to infection and on day 4 postchallenge, mice were given 0.5 mg of estradiol valerate (Delestrogen, King Pharmaceuticals) subcutaneously to maintain pseudoestrus. On the day of infection, the mice were anesthetized intraperitoneally with 80 mg/kg of body weight ketamine hydrochloride and then inoculated intravaginally with 20 μl of a suspension of 2 × 10⁸/ml CFU of C. albicans isolate 03-2718. The vaginal cavity of each mouse was swabbed (prior to treatment) 1 day after inoculation with C. albicans to ensure infection was consistently distributed among animals (10). Mice were swabbed on day 6 to evaluate the early treatment effects. Each alginate swab was placed in 0.9 ml sterile saline; serial 10-fold dilutions were made, and 100 μl was placed on Sabouraud dextrose agar supplemented with 0.5% (wt/vol) chloramphenicol to quantify the CFU/ml.ABC (Stiefel Laboratories, Inc., Coral Gables, FL) and FLC (Pfizer, Inc., New York, NY) were obtained in powder form from the manufacturers. ABC was prepared fresh daily and dissolved in 0.2% carboxymethylcellulose (low viscosity) with 1% Tween 80 (Sigma-Aldrich, St. Louis, MO). FLC was dissolved in distilled water. ABC was given by gavage once or twice daily at 5, 10, 20, or 40 mg/kg orally on days 1 through 5 postinoculation. FLC was administered by oral gavage once or twice daily at 20 mg/kg of body weight. All treatments were given in a volume of 0.2 ml. Control mice were infected but received no active treatment; one group received 0.2% carboxymethylcellulose with 1% Tween 80 and another sterile distilled water as vehicle controls.Comparisons were performed using the Mann-Whitney U test, with significance set at a P value of <0.05.The effects of ABC were compared with those of FLC for treatment of experimental vaginitis induced by an FLC-resistant isolate of C. albicans. The infection was evaluated 6 days after vaginal inoculation. The drug treatments were administered orally either once or twice daily for five consecutive days (days 1 to 5 postinoculation). Compared with results for vehicle-treated control mice, mice given doses of ABC at ≥20 mg/kg once daily greatly reduced vaginal loads of C. albicans (Table ​(Table1)1) (P < 0.01 to 0.0001). In addition, twice-daily administration of ABC at ≥10 mg/kg resulted in significant reductions of the vaginal load of C. albicans compared to results for single-dose administration. Oral administration with FLC at 20 mg/kg given once or twice a day significantly reduced the vaginal load of C. albicans (P < 0.008 to 0.001). A significant difference was found between the group that received ABC at 20 mg/kg once daily versus mice which received FLC at 20 mg/kg once daily (P = 0.02). However, there was no statistically significant difference in the fungal burden with the dose of 20 mg/kg twice daily of ABC or FLC (P = 0.07). Sterilization of the vaginal cavity was not observed with either the ABC or FLC regimen.

TABLE 1.

Recovery of C. albicans strain 03-2718 from vaginas of mice treated orally with ABC or FLC