Brucella Prosthetic Valve Endocarditis: A Systematic Review

ObjectiveBrucella prosthetic valve endocarditis is a rare but a life-threatening complication of brucellosis. It remains a diagnostic challenge. Optimal treatment of Brucella prosthetic valve endocarditis is debated. Available data is limited to case reports or small case series. The purpose of this study was to systematically review all published cases of Brucella prosthetic valve endocarditis in the literature.MethodA systematic review of PubMed database, Google, Google Scholar, and Scopus (From January 1974 to the present) for studies providing epidemiological, clinical and microbiological data as well as data on treatment and outcomes of Brucella prosthetic valve endocarditis was performed.ResultsA total of 51 reported cases were reviewed. Brucella melitensis (45%) and Brucella abortus (11.7%) were the most frequently isolated species. Most common type of prosthesis valve was mechanical prothesis (84.3%) and ten patients had double valve prosthesis (19.6%). Fever and dyspnea were present in 100% and 37.2% of the cases, respectively. The diagnosis was set with echocardiographic finding in 30 cases (93.7%), which revealed vegetation in 27 cases (84.3%). Most used antibiotics were rifampicin, doxycycline and aminoglycoside or cotrimoxazole. No deaths were noted in patients treated by combined medical and surgical treatment, but mortality was noted in 27.7% of the cases treated by antibiotics alone (p = 0.006).ConclusionThis systematic review highlights diagnostic challenges and demonstrates that surgery improved outcome by reducing mortality in patients treated with the combined surgical and medical treatment option. Brucellosis should be considered in the differential diagnosis of prosthetic valve endocarditis in patients residing in or traveling to areas of endemicity.     

Venetoclax ramp-up strategies for chronic lymphocytic leukaemia in the United Kingdom: a real world multicentre retrospective study

This retrospective, observational study evaluated patterns of inpatient versus outpatient tumour lysis syndrome (TLS) monitoring during venetoclax ramp-up in 170 patients with chronic lymphocytic leukaemia. The primary outcome was clinical/biochemical TLS. Two clinical and four biochemical TLS occurred (4.1%). Five of the six events occurred in high-risk patients, four occurred at 20 mg dose and three at the 6-h time-point. Inpatient versus outpatient TLS rates within the high-risk subgroup were 15% and 8%. Risk category was the only predictor of TLS events in multivariate analysis. Outpatient escalation did not associate with clinically meaningful TLS events, suggesting outpatient escalation has manageable associated TLS risks, including in high-risk cohorts. These observations require confirmation in larger studies.     

Treatment of painful bony metastases with Samarium 153-EDTMP in prostate carcinoma

THE OBJECTIVE of this work is to evaluate a new therapy, the metabolic radiotherapy to the 153Samarium-EDTMP, of recent introduction in Tunisia, in the painful bony metastasis treatment observed at the patients affected of cancer of the prostate. METHODS: It is about a retrospective survey with a receding of 40 months, achieved through 45 files of patients having benefited all of this new treatment for painful bony metastases in relation with a prostatic adenocarcinoma and collected by three centers of Nuclear Medicine of the capital: the institute Salah Azaiez (state-controlled), the Center CERU (deprives) and the Military hospital (HMPIT). RESULTS: We tried to appreciate essentially four parameters: the therapeutic efficiency, the factors influencing the answer in the treatment, the toxicity of the treatment and the sources of failure. We observed a positive answer in 92,1% of the cases, this answer was complete in 36,5% of the cases. The results gotten after multiple administrations show that the cures could be repeated with results comparable to those of the first cure. The therapeutic efficiency is at least equivalent to those of the other therapeutic means, with nearly non-existent secondary effects. The only toxicity is of hematological order; it is the most often moderate and reversible with a complete recuperation at the end of 8 weeks. Besides, the effect on the pain came with an improvement of the quality of life of the patients treaties. CONCLUSION: Its precocious introduction in the taken in charge of the metastatic patients, would allow them to benefit better from its efficiency, simplicity and weak toxicity and therefore to enjoy a better quality of life.     

Psoas abscess of the adult: study of 38 cases

OBJECTIVE: Our aim is to report the clinical aspects, the etiologies, the treatment and the evolution of the psoas abscess in the adult. METHODS: Our retrospective study concerns 38 cases of psoas abscesses collected in the Department of Infectious Diseases of Sfax (Tunisia), over a period of 16 years (January 1990 - December 2005). RESULTS: The average age is 44 years (extremes: 16-76 years). The sex-ratio is 1.4. Six patients were diabetics and one had a chronic renal injury at the stage of hemodialysis. The clinical manifestations were: a fever (76.4%), an abdomino-pelvic ache (84.2%) and a psoitis (34.2%). All patients had a biologic inflammatory syndrome with a hyperleucocytosis in 28 cases. The abscess was one-sided in 29 cases and bilateral in 9 cases. After microbiological study and/or histological study, pathogens were identified in 31 patients, they were Staphylococcus aureus (10 cases), Staphylococcus lugdunensis (1 case), Streptococci (3 cases), Escherichia coli (2 cases), Bacteroides fragilis (1 case), Actinomyces (2 cases), Brucella (3 cases), Mycobacterium tuberculosis (8 cases) and Candida glabrata (1 case). The psoas abscess was primary in 10 cases and secondary in 28 cases. All the patients received an antibiotherapy or an antifungal therapy adapted to the micro-organism in cause, with a drainage of the abscess in 25 cases (surgical in 9 cases and percutaneous in 16 cases). The evolution was favourable in 36 cases. One patient presented recurrences and one patient died. CONCLUSION: The psoas abscess of the adult is characterized by a polymorphe clinical presentation. Germs in cause are very variable.     

Thyroglobulin: usefulness and limits in monitoring patients with thyroid carcinoma

The aim of this study was to assess the role of thyroglobulin in monitoring patients with differentiated thyroid carcinoma. METHODS: We retrospectively sudied thirty patients who had total thyroidectomy and had been followed beteween 1999 and 2004 in nuclear medicine department. They have had iodine 131 whole body scans, repeated determination of thyroglobulin, thyreostimulin and thyroglobulin antibodies. RESULTS: One hundred twelve samples of thyroglobulin were done. In post surgical period thyroglobulin was ranging from 0.3 to 600 ng/ml. In 38 months follow up 4 patients (11.4%) had shown reccurent disease. Thyroglobulin sensitivity was 75%. One patient had diffuse lung metastases with high thyroglobulin level 600 ng/ml wich decreased after iodine 131 therapy. CONCLUSION: Serum thyroglobulin is the differentiated thyroid carcinoma marker of choice nevertheless one should establish the level of thyroid stimulation and seek for the antithyroglobulin antibodies.     

Characterization of CTX-M and SHV extended-spectrum beta-lactamases and associated resistance genes in Escherichia coli strains of food samples in Tunisia

OBJECTIVES: To assess the occurrence of extended-spectrum beta-lactamases (ESBLs) in Escherichia coli isolates of faecal samples of animals (n = 40) and food samples (n = 38) obtained in Tunisia in 2006, and to characterize the type of ESBLs, their genetic environments and the associated resistance genes. METHODS: Samples were inoculated in supplemented media (2 mg/L cefotaxime) for isolation of broad-spectrum cephalosporin-resistant E. coli isolates (one isolate/sample). ESBLs and their genetic environments as well as integrons and their gene cassette composition were characterized by PCR and sequencing. RESULTS: ESBL-producing E. coli isolates were detected in 10 of the 38 food samples analysed (26%) and in none of the tested animal faecal samples. Genes found were as follows (number of isolates): bla(CTX-M-1) (5), bla(CTX-M-1) + bla(TEM-1b) (1), bla(CTX-M-14) + bla(TEM-1b) (2), bla(CTX-M-8) (1) and bla(SHV-5) (1). All ESBL-positive isolates showed unrelated PFGE patterns. ISEcp1 and IS903 were detected surrounding bla(CTX-M-14), and ISEcp1/IS26 and orf477 surrounding some of the bla(CTX-M-1) genes. Four of the ESBL-positive strains harboured class 1 integrons including different gene cassette combinations. CONCLUSIONS: ESBLs, mainly of the CTX-M class, are detected in E. coli of food origin in Tunisia, being the first time that this mechanism has been detected in food E. coli strains in Africa.     

Prevalence and severity of hyponatremia and hypercreatininemia in short-term uncomplicated hypothyroidism

Hypothyroidism is widely accepted as a cause of hyponatremia and hypercreatininemia. However, the prevalence and severity of hyponatremia and hypercreatininemia in hypothyroid patients without comorbid conditions have not been well documented. We retrospectively studied serum sodium and creatinine levels in thyroid-ablated patients with differentiated thyroid cancer off (no.=128) and on (no.=60) thyroid hormone therapy. In the hypothyroid state, mean(+/-SD) TSH, sodium, and creatinine levels were 130.3+/-104.8 mU/l, 139.3+/-2.7 mEq/l, and 89.4+/-20 mmol/l respectively. Twenty-four patients (18.8%) had creatinine levels above the age- and sex-adjusted normal range, whereas only five patients (3.9%) had sodium levels below 135 mEq/l. No patient had a sodium level less than 130 mEq/l. Compared to their euthyroid values, mean sodium and creatinine levels of the hypothyroid patients changed by -1.18 mEq/l (p=0.003) and 17.2 mmol/l (p<0.0001), respectively. There was significant correlation of TSH levels in the hypothyroid state with the changes from the euthyroid state to the hypothyroid state in creatinine levels (r=0.29, p=0.02) but not with the corresponding changes in sodium levels (r=0.06, p=0.6). In thirty-seven patients studied in two hypothyroid episodes, there was a significant correlation between a) TSH levels in hypothyroid state 1 and hypothyroid state 2 (r=0.56, p=0.0003), and b) the change in creatinine levels from the euthyroid state to hypothyroid state 1 and the corresponding change from the euthyroid state to hypothyroid state 2 (r=0.48, p=0.003). There was no significant correlation between the change in sodium levels from the euthyroid state to hypothyroid state 1 and the corresponding change from the euthyroid state to hypothyroid state 2 (r=0.32, p=0.05). We conclude that hyponatremia is very uncommon, whereas mild to moderate elevation in serum creatinine level is not uncommon in patients with short-term uncomplicated hypothyroidism.     

Chronic lymphocytic leukemia revealed by a branulomatous zosteriform eruption

A 70-year-old woman presented with an atypical erythematopapular zosteriform eruption of 3 weeks' duration. The patient had no history of previous vesicular eruption. She developed a painful burning sensation on the neck. Clinical examination revealed a cluster of small erythematous firm papules and plaques in a zosteriform distribution on the left ear, face, neck, and shoulder (Figure 1A). The lesions were unilateral and did not cross the midline. Multiple cervical and axillary lymph nodes were palpable. Laboratory tests revealed an increase in white blood cells of 25,000/mm3, with 17,910/mm3 lymphocytes and a normal range of hemoglobin, platelets, creatinine, and liver enzymes. Erythrocyte sedimentation rate was 87 mm. Blood smear results showed small, morphologically mature lymphocyte cells. In immune phenotyping, lymphocyte cells co-express CD5 and B-cell-surface antigens CD19 and CD23, as well as a restriction of kappa immunoglobulin light chains. The cells were CD22-, CD79b-, CD38-, CD10-, CD25- and FMC7-. Computed thoracoabominal tomography revealed cervical, mediastinal, abdominal, and pelvic adenopathy confirming the diagnosis of B-cell chronic lymphocytic leukemia (B-CLL) stage B. Histology of a skin biopsy from a papule showed a dense nodular granulomatous infiltrate in the dermis (Figure 2A). The infiltrate contained epithelioid and giant cells surrounded by lymphocytes and plasma cells. Small monomorphic lymphocytes without mitotic figures predominated (Figure 2B). The epidermis was irregularly thickened. Immunohistology revealed a polymorphous infiltrate with a phenotype of reactive T lymphocytes (CD3, CD5 positive) (Figure 2C), B lymphocytes (CD20 positive) (Figure 2D). Epithelioid and giant cells were positive for CD68 (Figure 2E). A latent herpes zoster infection with granulomatous reaction at the site ofzoster lesions was highly suspected as the patient reported a unilateral burning sensation without a history of vesicular zosteriform eruption. She received treatment with intravenous acyclovir 10 mg/kg every 8 hours. The papular lesions resolved markedly (60%) on macular plaques at the end of the treatment. Following topical treatment with corticosteroids, the lesions healed completely within 4 weeks (Figure 1B). Concerning leukemia, our patient was monitored without therapy by the hematologist.