De la rigidez de nuca y fiebre, a la endocarditis de causa infrecuente: cerebro y corazón, unidos por la patogenia

We report the case of a 69-year-old woman who consulted in the emergency department for depressed level of consciousness, fever, nuchal rigidity, and shock. The diagnostic tests became an infrequent diagnosis: acute endocarditis caused by Escherichia coli. The computed tomography of the head showed lesions which were compatible with septic emboli. Only 0.51% of endocarditis are caused by Escherichia coli, and they are associated with a high rate of complications and mortality. Treatment of endocarditis caused by gram-negative organisms is controversial; we proposed cardiac surgery in our patient, however it was rejected because she had a good clinical response to antibiotic treatment.Presentamos el caso de una mujer de 69 años que consulta en Urgencias por bajo nivel de consciencia, fiebre, rigidez de nuca y shock. Las pruebas diagnósticas devinieron en un diagnóstico infrecuente: endocarditis aguda por Escherichia coli. Se realizó tomografía axial computarizada de cráneo que mostraba lesiones compatibles con émbolos sépticos. Sólo un 0,51% de las endocarditis están causadas por Escherichia coli, y se relacionan con una alta tasa de complicaciones y elevada mortalidad. El tratamiento de la endocarditis por microorganismos gramnegativos es controvertido; en nuestra paciente, se planteó cirugía cardíaca, aunque se desestimó por buena respuesta al tratamiento antibiótico

Diabetes mellitus tipo MODY 1

We show a 24-year-old Arab patient who was admitted to severe pneumococcal pneumonia. During the ad- mission she was diagnosed with type-2 diabetes, overweight and hypertriglyceridemia. The autoimmunity was negative and the C-peptide was normal as well. After starting treatment with metformin and fibrates the metabolic control improved, nevertheless she eventually required the start of a second antidiabetic drug with iSGLT-2. Due to the fact that there was not entirely favorable evolution and the lack of obesity, we decided to rule out a MODY. Genetic tests confirmed a mutation in the HNF4A gene. She was diagnosed with MODY-1.Se trata de una paciente de 24 años de raza árabe que acude por neumonía neumocócica grave, diagnosticándose en el ingreso de diabetes mellitus tipo 2 con sobrepeso e hipertrigliceridemia. La autoinmunidad fue negativa y el péptido C normal. Tras inicio de tratamiento con metformina y fibratos, la paciente mejoró clínicamente, pero evolutivamente precisó inicio de un segundo fármaco con inhibidores del cotransportador 2 de sodio y glucosa (iSGLT-2), dado el sobrepeso que presentaba. Ante esta evolución no del todo favorable sin obesidad se planteó la posibilidad de que se tratara de MODY, solicitándose los test genéticos que confirmaron una mutación en el gen HNF4A

Blood culture-negative infective endocarditis: a worse outcome? Results from a large multicentre retrospective Spanish cohort study

[Background] To assess the impact of blood cultures negative infective endocarditis (BCNIE) on in-hospital mortality.[Methods] Prospective multicentre study with retrospective analysis of a Spanish cohort including adult patients with definite IE. Cardiac implantable devices infection were excluded. Comparisons between blood cultures positive and BCNIE groups were performed to analyse in-hospital mortality.[Results] 1001 cases were included of which 83 (8.3%) had BCNIE. Alternative microbiological diagnosis was achieved for 39 (47%) out 83 cases. The most frequent identifications were: Coxiella burnetii (11; 28.2%), Tropheryma whipplei (4; 10.3%), Streptococcus gallolyticus (4;10.3%) and Staphylococcus epidermidis (3; 7.7%). Surgery was performed more frequently in BCNIE group (57.8 vs. 36.9%, p < .001). All-cause in-hospital mortality rate was 26.7% without statistical difference between compared groups. BCNIE was not associated to worse mortality rate in Cox regression model (aHR = 1.37, 95% CI 0.90–2.07, p = .14). Absence of microbiological diagnosis was also not associated to worse in-hospital prognosis (aHR = 1.62, 95% CI 0.99–2.64, p = .06).[Conclusions] In our cohort, BCNIE was not associated to greater in-hospital mortality based in multivariate Cox regression models. The variables most frequently associated with mortality were indicated but not performed surgery (aHR = 2.48, 95% CI 1.73–3.56, p < .001), septic shock (aHR = 2.24, 95% CI 1.68–2.99, p < .001), age over 65 years (aHR = 1.88, 95% CI 1.40-2.52, p < .001) and complicated endocarditis (aHR = 1.79, 95% CI 1.36–2.37, p < .001).Peer reviewe

Spatiotemporal Characteristics of the Largest HIV-1 CRF02_AG Outbreak in Spain: Evidence for Onward Transmissions

Background and Aim: The circulating recombinant form 02_AG (CRF02_AG) is the predominant clade among the human immunodeficiency virus type-1 (HIV-1) non-Bs with a prevalence of 5.97% (95% Confidence Interval-CI: 5.41–6.57%) across Spain. Our aim was to estimate the levels of regional clustering for CRF02_AG and the spatiotemporal characteristics of the largest CRF02_AG subepidemic in Spain.Methods: We studied 396 CRF02_AG sequences obtained from HIV-1 diagnosed patients during 2000–2014 from 10 autonomous communities of Spain. Phylogenetic analysis was performed on the 391 CRF02_AG sequences along with all globally sampled CRF02_AG sequences (N = 3,302) as references. Phylodynamic and phylogeographic analysis was performed to the largest CRF02_AG monophyletic cluster by a Bayesian method in BEAST v1.8.0 and by reconstructing ancestral states using the criterion of parsimony in Mesquite v3.4, respectively.Results: The HIV-1 CRF02_AG prevalence differed across Spanish autonomous communities we sampled from (p &lt; 0.001). Phylogenetic analysis revealed that 52.7% of the CRF02_AG sequences formed 56 monophyletic clusters, with a range of 2–79 sequences. The CRF02_AG regional dispersal differed across Spain (p = 0.003), as suggested by monophyletic clustering. For the largest monophyletic cluster (subepidemic) (N = 79), 49.4% of the clustered sequences originated from Madrid, while most sequences (51.9%) had been obtained from men having sex with men (MSM). Molecular clock analysis suggested that the origin (tMRCA) of the CRF02_AG subepidemic was in 2002 (median estimate; 95% Highest Posterior Density-HPD interval: 1999–2004). Additionally, we found significant clustering within the CRF02_AG subepidemic according to the ethnic origin.Conclusion: CRF02_AG has been introduced as a result of multiple introductions in Spain, following regional dispersal in several cases. We showed that CRF02_AG transmissions were mostly due to regional dispersal in Spain. The hot-spot for the largest CRF02_AG regional subepidemic in Spain was in Madrid associated with MSM transmission risk group. The existence of subepidemics suggest that several spillovers occurred from Madrid to other areas. CRF02_AG sequences from Hispanics were clustered in a separate subclade suggesting no linkage between the local and Hispanic subepidemics