Acute varicella-zoster virus necrotizing meningoencephalomyelitis with sudden visual loss and paraparesis in an HIV-infected patient

We describe a case of acute varicella-zoster virus (VZV) hemorrhagic meningoencephalomyelitis in an HIV-infected patient. On admission the patient's CSF was mild haemorrhagic and xanthochromic after centrifugation and he had thoracic skin blisters. VZV DNA was isolated from both the thoracic blisters and CSF. Treatment consisted of aggressive antiviral, steroid and immunoglobulin therapy, which was able to stop disease progression. The patient survived but was left blind and paretic. In conclusion, a diagnosis of CNS infection caused by VZV, based upon CSF analysis and examination of the skin for typical blisters, requires aggressive empiric antiviral therapy in order to maximise patient survival

Comparison and combination of a hemodynamics/biomarkers-based model with simplified PESI score for prognostic stratification of acute pulmonary embolism: findings from a real world study

Background: Prognostic stratification is of utmost importance for management of acute Pulmonary Embolism (PE) in clinical practice. Many prognostic models have been proposed, but which is the best prognosticator in real life remains unclear. The aim of our study was to compare and combine the predictive values of the hemodynamics/biomarkers based prognostic model proposed by European Society of Cardiology (ESC) in 2008 and simplified PESI score (sPESI).Methods: Data records of 452 patients discharged for acute PE from Internal Medicine wards of Tuscany (Italy) were analysed. The ESC model and sPESI were retrospectively calculated and compared by using Areas under Receiver Operating Characteristics (ROC) Curves (AUCs) and finally the combination of the two models was tested in hemodinamically stable patients. All cause and PE-related in-hospital mortality and fatal or major bleedings were the analyzed endpointsResults: All cause in-hospital mortality was 25% (16.6% PE related) in high risk, 8.7% (4.7%) in intermediate risk and 3.8% (1.2%) in low risk patients according to ESC model. All cause in-hospital mortality was 10.95% (5.75% PE related) in patients with sPESI score ≥1 and 0% (0%) in sPESI score 0. Predictive performance of sPESI was not significantly different compared with 2008 ESC model both for all cause (AUC sPESI 0.711, 95% CI: 0.661-0.758 versus ESC 0.619, 95% CI: 0.567-0.670, difference between AUCs 0.0916, p=0.084) and for PE-related mortality (AUC sPESI 0.764, 95% CI: 0.717-0.808 versus ESC 0.650, 95% CI: 0.598-0.700, difference between AUCs 0.114, p=0.11). Fatal or major bleedings occurred in 4.30% of high risk, 1.60% of intermediate risk and 2.50% of low risk patients according to 2008 ESC model, whereas these occurred in 1.80% of high risk and 1.45% of low risk patients according to sPESI, respectively. Predictive performance for fatal or major bleeding between two models was not significantly different (AUC sPESI 0.658, 95% CI: 0.606-0.707 versus ESC 0.512, 95% CI: 0.459-0.565, difference between AUCs 0.145, p=0.34). In hemodynamically stable patients, the combined endpoint in-hospital PE-related mortality and/or fatal or major bleeding (adverse events) occurred in 0% of patients with low risk ESC model and sPESI score 0, whilst it occurred in 5.5% of patients with low-risk ESC model but sPESI ≥1. In intermediate risk patients according to ESC model, adverse events occurred in 3.6% of patients with sPESI score 0 and 6.65% of patients with sPESI score ≥1.Conclusions: In real world, predictive performance of sPESI and the hemodynamic/biomarkers-based ESC model as prognosticator of in-hospital mortality and bleedings is similar. Combination of sPESI 0 with low risk ESC model may identify patients with very low risk of adverse events and candidate for early hospital discharge or home treatment.

Efficacy of fidaxomicin therapy, after failure of vancomycin therapy, for treating a C. difficile colitis in a patient with ulcerative colitis

Patients with inflammatory bowel diseases (IBDs) have greater risk of developing C. difficile infection (CDI). In these patients, CDI have worse outcome, may be associated with increased risk of bacteremia and candidemia and may be misdiagnosed as relapse of IBD, also because ofthe absence of typical findings of CDI at colonoscopy. A 58-year-old man with acute ulcerative colitis treated with steroids was hospitalized for feverand recrudescence of inflammatory diarrhea. During the hospitalization, the fever was treated with broad spectrum antibiotics and systemic anti-fungal therapy. Candida mannan antigenand the molecular screening for C. difficile resulted positive. A first course of vancomycin by mouthwas unsuccessful, therefore we started a 10-day course of fidaxomicin. After five days of therapy, diarrhea disappeared. A few-week course of fluconazole therapy was performed to complete the treatment of invasive candidiasis. At six-month follow-up no relapse of CDI was documented

Case Report of a Successful Treatment of Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia and MRSA/Vancomycin-Resistant Enterococcus faecium Cholecystitis by Daptomycin▿

A 72-year-old man, receiving 8 mg daptomycin/kg body weight/day for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, was diagnosed with MRSA/vancomycin-resistant Enterococcus faecium (VRE) cholecystitis (daptomycin MIC values, 1 and 2 mg/liter, respectively). After the fifth drug dose, the bile concentration of daptomycin was 66 mg/liter 5 min after drug administration, with the biliary concentration/MIC values higher than 30 for both bacterial strains. Therefore, daptomycin achieved therapeutic levels in bile, hence suggesting a role for the drug in the treatment of MRSA/VRE cholecystitis

Three-times weekly teicoplanin as outpatient treatment of chronic osteoarticular infections

Treatment of difficult-to-treat infections such as osteomyelitis or infections related to indwelling medical devices requires lengthy antibiotic therapy and adequate surgical debridement. Teicoplanin, a glycopeptide antibiotic with a long half-life, was used three-times weekly in the treatment of these infections. After a period of daily dosing with teicoplanin, patients were treated with an intravenous dose of 12 mg on mondays, wednesdays and fridays. A control group of patients were treated with teicoplanin daily. Teicoplanin levels were measured during the study. Thirty-six patients were enrolled in the study: 14 with vertebral osteomyelitis, 12 with infected orthopedic implants, 7 with osteomyelitis and 3 with arterial prosthetic infections. The duration of treatment ranged from 60 to 360 days. Cure was obtained in 21 (58%) patients and improvement in 15 (42%) patients. Trough and peak serum concentrations in three-time weekly patients were 16.2+/-7.2 mg/l and 58.7+/-14.4 mg/l. In the control group trough and peak serum concentrations were 18.9+/-13.6 mg/l and 52.2+/-27 mg/l. Adverse events occurred in 6 patients: mainly mild liver toxicity. Three times weekly teicoplanin seems to be a valuable option in the treatment of chronic infections

Myelomatous meningitis evaluated by multiparameter flow cytometry : report of a case and review of the literature.

Central nervous system (CNS) involvement in multiple myeloma (MM) is uncommon. Among its possible presentations, leptomeningeal involvement of MM, also termed central nervous system myelomatosis (CNS-MM) is rare and is characterized by the presence of neoplastic plasma cells in the cerebrospinal fluid (CSF). So far, 187 cases of CNS-MM have been reported : the great majority of them were diagnosed by cytological assays and flow cytometry was used in only eight cases. We describe a case of CNS-MM in a 62-year-old woman, previously treated with chemotherapy (VTD) and autologous peripheral blood hematopoietic stem cell transplantation for stage IIIB IgG-λ MM. After achieving a very good partial response, the patient showed progression of disease, with an extramedullary localization. During administration of second-line therapy, the patient showed severe neurological symptoms. MRI resulted negative. Diagnosis of CNS-MM was made by multiparameter flow cytometry, which showed the presence of CD56(+) plasma cells in a CSF sample, in the absence of plasma cell leukemia. In this paper we also present a review of the eight previous cases of CNS-MM diagnosed by flow cytometry. We found that the application of flow cytometry in cases of MM with neurological symptoms allows a rapid diagnosis of CNS-MM and provides useful information about plasma cell phenotype (including CD56 expression). Some cases of CNS-MM are characterized by normal MRI. In addition, some evidences deriving from the review of literature suggest that CSF monitoring by flow cytometry in such cases might be used to evaluate the efficacy of drugs capable of crossing the blood-brain barrier

Acute varicella-zoster virus necrotizing meningoencephalomyelitis with sudden visual loss and paraparesis in an HIV-infected patient

We describe a case of acute varicella-zoster virus (VZV) hemorrhagic meningoencephalomyelitis in an HIV-infected patient. On admission the patient's CSF was mild haemorrhagic and xanthochromic after centrifugation and he had thoracic skin blisters. VZV DNA was isolated from both the thoracic blisters and CSF. Treatment consisted of aggressive antiviral, steroid and immunoglobulin therapy, which was able to stop disease progression. The patient survived but was left blind and paretic. In conclusion, a diagnosis of CNS infection caused by VZV, based upon CSF analysis and examination of the skin for typical blisters, requires aggressive empiric antiviral therapy in order to maximise patient survival

Discordant lymphoma consisting of splenic mantle cell lymphoma and marginal zone lymphoma involving the bone marrow and peripheral blood: a case report

<p>Abstract</p> <p>Introduction</p> <p>Discordant lymphomas are rare entities characterized by the simultaneous presence of two distinct types of lymphomas in different anatomic sites. We describe a very rare case of simultaneous occurrence of splenic mantle cell lymphoma and marginal zone lymphoma involving the bone marrow and peripheral blood.</p> <p>Case presentation</p> <p>We report the case of a 60-year-old asymptomatic Caucasian woman in whom discordant lymphomas were discovered when a slight lymphocytosis and a conspicuous splenomegaly were observed. The different morphological, immunophenotypical and immunohistochemical features found in the different pathologic samples obtained from peripheral blood, bone marrow and spleen sections made it possible to differentiate two types of non-Hodgkin B-cell lymphomas: a mantle cell lymphoma infiltrating the spleen and a marginal zone lymphoma involving both the bone marrow and peripheral blood. Since a similar IgH gene rearrangement was found both in the bone marrow and in the spleen, the hypothesis of a common origin, followed by a different clonal selection of the neoplastic lymphocytes may be taken into consideration.</p> <p>Conclusion</p> <p>Our case emphasizes the usefulness of investigating simultaneous specimens from different anatomic sites from the same patient and the relevant diagnostic role of splenectomy.</p