Cinzia Hu

Severity assessment of healthcare-associated pneumonia and pneumonia in immunosuppression

The study compares the ability of the PSI (pneumonia severity index), CURB-65 (confusion, urea >7 mol·L−1, respiratory rate ≥30 breaths·min−1, blood pressure <90 mmHg systolic or ≤60 mmHg diastolic, and age ≥65 yrs), CURB and CRB-65 scales and the Severe Community-Acquired Pneumonia (SCAP) score to predict 30-day mortality in healthcare-associated pneumonia (HCAP) patients, and analyses differences in the demographics, aetiology and outcomes of community-acquired pneumonia (CAP), HCAP and pneumonia in immunocompromised patients. 629 consecutive patients admitted to a tertiary care university hospital were prospectively categorised as having CAP (n=322) or HCAP (n=307), and the HCAP patients were further sub-divided into those who were immunocompromised (n=219) or immunocompetent (n=88). The 30-day mortality rate was 9.0% in the CAP group and 24.1% in the HCAP group. In the HCAP group, the PSI and SCAP scores had similar prognostic power (area under the curve (AUC) of 0.68 and 0.67, respectively) and performed better than the CURB-65 score (AUC ≤0.62). Among the immunocompetent HCAP patients, the PSI and CURB-65 scores were more sensitive than the others at every threshold, whereas SCAP was more specific than both of these. In the immunocompromised group, the PSI was highly sensitive but poorly specific at all thresholds. Our results suggest that prognostic tools should be designed for subsets of HCAP patients.

Invasive fungal sinusitis: An effective combined treatment in five haematological patients

Invasive fungal rhinosinusitis (IFR) is a life-threatening infection. Its onset is subtle and a late diagnosis leads to severe complications. Death may occur within a few weeks notwithstanding treatment. We describe a comprehensive pre- and post-operative approach to care for haematological patients with IFR. Five haematological patients with IFR were treated with systemic antifungal therapy and endoscopic surgical debridement of infected tissues, followed by amphotericin-B directly instilled in the sinuses by a new type of ethmoidal drainage. The IFR remitted in all cases; after 32 months of follow-up, three patients are still alive, and two have died of other causes. Two of the patients who experienced IFR progression to the brain at the IFR onset are still alive. The pharmacological and surgical approach with the post-operative local therapy by a new ethmoidal drainage system could support radical antifungal sinus treatment, thus improving the overall survival.

Ehlers–Danlos Syndrome in an Adult Woman: A Hidden Syndrome

Ehlers–Danlos syndrome is a rare disease and a diagnostic challenge. This case report serves to remind the clinician that it is important to identify all affected patients in order to prevent complications.

Challenges in dealing with a cirrhotic patient

Dr. Spinelli We report a case of a 75-year-old woman with Child-Pugh Class 7 B HCV cirrhosis, admitted to our hospital for high fever (38.5 C), chills and fatigue. These symptoms started approximately 1 month prior, and progressively worsened. At home, she was treated with levofloxacin without benefit. She reported anorexia and loss of weight of 4 kg. A recent upper-digestive endoscopy (EGDS) showed fine caliber esophageal varices; the ultrasonography of the abdomen revealed signs of chronic liver disease and splenomegaly. The patient was alert and oriented, even if a bit slackened. On physical examination, she had no sign of meningismus and no jaundice. Vital signs: body temperature 37.5 C, heart rate 72 beats/min, blood pressure of 100/60 mmHg. Oxygen saturation by pulse oximetry was 95 % on room air. Body mass index (BMI): 19.9. Cranial nerve examination was normal. She had minimal ascites and hepatomegaly. There was edema of grade-2 in the lower extremity bilaterally. The rest of the general body examination was normal. Blood laboratory tests revealed a sever iron deficiency anaemia (haemoglobin 7.6 g/dl), increased transaminases, low pseudocholinesterase and hypoalbuminemia. Inflammation indices were negative. She was transfused with several red blood cells (RBC) units, and was initially treated with ceftriaxone without benefit. She was initially supported with a balanced hypoproteinemic low-sodium oral diet. Because of worsening deterioration of the general condition, she was also treated with parenteral nutrition (aminoacid solution, vitamins, glucose, electrolytes, lipids) for a total caloric contribution of 1,320 kcal/daily.

Prolonged PT and aPTT in a patient with severe proteinuria

Dr. Motta and Dr. Migone: A 70-year-old woman was admitted to our medical unit because of severe leg and pedal edema and peripheral paresthesias gradually developed during the prior 3 months; she was suffering from cramps during the previous week. The patient had a history of hypertension and type 2 diabetes (glycated hemoglobin 6.4 %) well-controlled by oral hypoglycemic drugs for the last 6 years. Ten months prior to admission, blood and urinalysis were normal, ophthalmologic examination and US Doppler of legs arteries did not show pathological signs. Six months before admission, the patient underwent surgery for a carpal tunnel syndrome. She also underwent hysterectomy 20 years prior and cholecystectomy 40 years prior; both surgeries were uncomplicated. The home treatment during the prior 3 months was candesartan/hydrochlorothiazide, allopurinol, nebivolol, amlodipine, gliclazide, cardioaspirin. At admission, the patient was alert and cooperative. Blood pressure was 130/70 mmHg, pulse 98 beats/min and saturation was 96 % on room air. BMI was 34. On examination, she was pale and had severe bilateral legs edema from the knees. Peripheral pulses were good distally. The chest was clear and a 2/6 systolic murmur was heard. The abdomen was obese, soft, non tender, non distended, no hepatosplenomegaly was appreciated; bowel sounds were active. On neurologic examination she complained paresthesias of the extremities, no focal deficits were present. Blood tests revealed a mild renal insufficiency (serum creatinine 1.38 mg/dl, MDRD GFR 40 ml/min/1.73 mq, BUN 91 mg/dl) that rapidly worsened, with severe hyperkalemia and hypoalbuminemia. A nephrotic proteinuria associated with a mild microscopic hematuria was detected (Table 1).

What does acute dyspnea hide

Case presentationDr. Giovanna Squiccimarro In December 2009, a previ-ously healthy 48-year-old man was admitted because ofhypertensive crisis and bilateral diffuse ground-glassshadows on the chest X-ray study.He presented at the Emergency Department (ED) com-plaining of worsening dyspnea.The respiratory rate was 35 breaths/min and SpO2 93%at pulse oximeter. His blood pressure (BP) was 220/120mmHg and the heart rate 120 beats/min.He was overweight, afebrile and diaphoretic. He had ahistory of alcohol and tobacco abuse (more than 20 ciga-rettes/day). He denied use of any medications, and reportedthat mild dyspnea and fever (TA 39 C) acutely began3 weeks prior. The fever resolved without any therapy in afew days but a mild dyspnea persisted.Ten days prior to admission, dyspnea was still presentand an isolated hemoptysis occurred.Normal lung breath sounds and a 3/6 heart systolicmurmur were heard on the examination. The electrocar-diogram (EKG) showed sinus tachycardia, right bundle-branch block and S1–Q3 pattern.Arterial blood gas (ABG) analysis while breathing roomair showed pH 7.47, PaO2 57 mmHg, pCO2 33 mmHg,HCO3- 25.4 mmol/L. Laboratory tests were normalexcept for WBC count 10,200/mmc (N = 80%), C-RP1.31 mg/dL (normal range\0.5), creatinine 1.4 mg/dL,K

Metastatic Spreading of Community Acquired Staphylococcus aureus Bacteraemia

A 29-year-old woman presented to the Fondazione IRCCS “Cà Granda” Ospedale Maggiore, a tertiary care university hospital in Milan (Italy), with skin lesions, fever, myalgia, joint pain and swelling, and a one-week history of low back pain. The diagnosis was Staphylococcus aureus (S. aureus) bacteraemia spreading to skin, bones, and joints and a lumbosacral epidural abscess L5-S2. Neither initial focus nor predisposing conditions were apparent. The antibiotic therapy was prolonged for six-weeks with the resolution of fever, skin lesions, articular inflammation, and the epidural abscess. Community-acquired S. aureus infections can affect patients without traditional healthcare-associated risk factors, and community acquisition is a risk-factor for the development of complications. Raised awareness of S. aureus bacteraemia, also in patients without healthcare-associated risk factors, is important in the diagnosis, management, and control of this infection, because failure to recognise patients with serious infection and lack of understanding of empirical antimicrobial selection are associated with a high mortality rate in otherwise healthy people.