Dunja Wilmes

Streptococcus gordonii septic arthritis: two cases and review of literature.

BackgroundDespite advances in antimicrobial and surgical therapy, septic arthritis remains a rheumatologic emergency that can lead to rapid joint destruction and irreversible loss of function. In adults, Staphylococcus aureus is the most common microorganism isolated from native joints. Streptococcus gordonii is a prominent member of the viridans group of oral bacteria and is among the bacteria most frequently identified as being primary agent of subacute bacterial endocarditis. To the best of our knowledge, Streptococcus gordonii has not yet been described as agent of septic arthritis.Case PresentationWe describe here two cases of septic arthritis due to Streptococcus gordonii. It gives us an opportunity to review epidemiology, diagnosis criteria and management of septic arthritis.ConclusionAlthough implication of S. gordonii as aetiologic agent of subacute endocarditis is well known, this organism is a rare cause of septic arthritis. In this case, the exclusion of associated endocarditis is warranted.

Osteomyelitis pubis caused by Kingella kingae in an adult patient: Report of the first case

BackgroundKingella kingae is the second most common pathogen causing paediatric arthritis and is described to be the causative bacteria in some paediatric osteomyelitis. Its microbiological detection is particularly difficult due to its slow growing. To our best knowledge this is the first case description of osteomyelitis pubis caused by this microorganism.Case presentationWe report the unusual case of pubic osteomyelitis with soft tissue abcess caused by Kingella kingae in an adult patient of 66 years with a history of end-stage renal disease and breast carcinoma. Diagnosis was based on imaging and the microorganism was isolated from Computed Tomography-guided aspiration of synovial fluid. The infection resolved completely after twelve weeks of treatment with oral amoxicillin.ConclusionThis case description highlights the importance in osteoarticular infections of systematic inoculation of synovial liquid in BACTEC vials to optimise the detection of causative organisms, which can necessitate specific treatments.

Late presentation for human immunodeficiency virus HIV diagnosis results of a Belgian single centre

Abstract Background Antiretroviral therapy reduces mortality and morbidity in HIVinfected individuals, most markedly when initiated early, before advanced immunodeficiency has developed. Although the international guidelines recommend starting antiretroviral therapy ART with a high CD4 cell count level, in the practice, this is particularly challenging to achieve, especially in late presentation of HIV diagnosis. The aim of this study was to determine the frequency and the demographic features associated with late presentation for HIV diagnosis in our Centre. Methods All newly diagnosed patients with HIV between January 2007 and December 2011 in our AIDS Reference Centre, were included. Late presenter patient was defined as patient with CD4 count 350mm3 at the time of diagnosis. Demographic age, sex, ethnicity, migration and clinical characteristics transmission mode, CD4 cell count, viral load were collected. We also collected data on outcome median day of hospitalization, mortality, virological response to ART and lost to followup LTFU. LTFU was defined as patient without any medical contact and viral load measurements during two consecutive years in our centre. Results From 2007 to 2011, 154 429 out of 359 patients newly diagnosed with HIV were late presenters. According to univariate analysis, age 50, female gender, migrant from subSaharan Africa and heterosexual contact were associated with late presentation for HIV diagnosis. In the multivariate analysis, age 50, heterosexual contact and migrant status particularly women were the only independent risk factors for late presentation. Late presenters tend to have a worse outcome than nonlate presenters. Conclusion A considerable proportion of patients continue to be diagnosed with advanced HIV disease, despite the fact that risk factors for late presentation have been clearly identified. Despite high testing rate for HIV in Belgium, highrisk population like migrant, heterosexual contact, remain under tested. In order to be able to detect and treat all patients with high CD4 cell count as recommended by all international guidelines, we recommend developing testing policies specifically focused on these categories at high risk for late presentation.

NEUROARTHROPATHY SECONDARY TO TRANSTHYRETIN AMYLOIDOSIS (ATTR V30M)

Abstract In this article we report the case of a 46-years-old Portuguese woman admitted in our orthopaedic ward with right knee pain. Radiological findings were consistent with neuroarthropathy. After exclusion of the most common causes of polyneuropathy, Familial amyloid polyneuropathy (FAP) was diagnosed by the discovery of a mutation V30M on chromosome 18 by polymerase chain reaction on a fibroblast culture of her skin biopsy. FAP is one of many aetiologies of polyneuropathy. Although a rare disease, genetic screening in selected populations makes early diagnosis and prompt treatment of asymptomatic family members readily available.

Fever and lymphadenitis in an immunocompromised patient

Abstract Objective and importance: Bartonella henselae infections are among the most common causes of fever and lymphadenopathies, but can lead to severe complications in immunocompromised hosts; early recognition of these infections is of paramount importance in immunocompromised patients. Clinical presentation: Here we report the case of a renal transplant recipient who presented with fever, lymphadenopathies, and a splenic abscess secondary to Bartonella henselae infection, successfully treated with doxycycline. Discussion and conclusions: We discuss the various clinical presentations of Bartonella henselae infections in immunocompromised patients and the available diagnostic tools for this potentially severe complication.

Necrotizing ANCA-Positive Glomerulonephritis Secondary to Culture-Negative Endocarditis

Infective endocarditis (IE) and small-vessel vasculitis may have similar clinical features, including glomerulonephritis. Furthermore the association between IE and ANCA positivity is well documented, making differential diagnosis between IE- and ANCA-associated vasculitis particularly difficult, especially in case of culture-negative IE. We report on one patient with glomerulonephritis secondary to culture-negative IE caused by Bartonella henselae which illustrates this diagnostic difficulty.

Candida glabrata Renal Abscesses in a Peritoneal Dialysis Patient

1. Taylor G, McKenzie M, Buchanan–Chell M, Perry D, Chui L, Dasgupta M. Peritonitis due to Stenotrophomonas maltophilia in patients undergoing chronic peritoneal dialysis. Perit Dial Int 1999; 19:259–62. 2. Baek JE, Jung EY, Kim HJ, Lee GW, Hahm JR, Kang KR, et al. Stenotrophomonas maltophilia infection in patients receiving continuous ambulatory peritoneal dialysis. Korean J Intern Med 2004; 19:104–8. 3. Shukla A, Abreu Z, Bargman JM. Streptococcal PD peritonitis—a 10-year review of one centre’s experience. Nephrol Dial Transplant 2006; 21:3545–9. 4. Kiddy K, Brown PP, Michael J, Adu D. Peritonitis due to Streptococcus viridans in patients receiving continuous ambulatory peritoneal dialysis. Br Med J (Clin Res Ed) 1985; 290:969–70. 5. Machuca E, Ortiz AM, Rabagliati R. Streptococcus viridans– associated peritonitis after gastroscopy. Adv Perit Dial 2005; 21:60–2. 6. Hammann R. A reassessment of the microbial flora of the female genital tract, with special reference to the occurrence of Bacteroides species. J Med Microbiol 1982; 15:293–302. doi:10.3747/pdi.2011.00038

Bacterial pneumonia in kidney transplant recipients

Bacterial pathogens are the most frequent cause of pneumonia after transplantation. Early after transplantation, recipients are at higher risk for nosocomial infections. The most commonly encountered pathogens during this period are gram-negative bacilli (Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa …), but gram-positive coccus such as Staphylococcus aureus or Streptococcus pneumoniae and anaerobic bacteria can also be found. Empirical antibiotic therapy should be guided by previous colonisation of the recipient and bacterial resistance pattern in the hospital. Six months after transplantation, pneumonias are mostly due to community-acquired bacteria (S. pneumonia, H. influenza, Mycoplasma, Chlamydia and others). Opportunistic pathogens take advantage of the state of immunosuppression which is usually highest from one to six months after transplantation. During this period, but also occurring many years later in the setting of a chronically depressed immune system, bacterial pathogens with low intrinsic virulence can cause pneumonia. The diagnosis of pneumonia caused by opportunistic pathogens can be challenging. The delay in diagnosis preventing the early instauration of adequate treatment in kidney transplant recipients with a depressed immune system, frequently coupled with co-morbid conditions and a state of frailty, will affect prognosis and outcome, increasing morbidity and mortality. This review will focus on the most common opportunistic bacterial pathogens causing pneumonia in kidney transplant recipients: Legionella, Nocardia, Mycobacterium tuberculosis/nontuberculous, and Rhodococcus. Recognition of their specificities in the setting of immunosuppression will allow early diagnosis, crucial for initiation of effective therapy and successful outcome. Interactions with immunosuppressive therapy should be considered as well as reducing immunosuppression if necessary.

Cutaneous Mycobacterium chelonae infection distal to the arteriovenous fistula.

A few single cases of Mycobacterium chelonae skin infection have been reported in haemodialysis patients. We report three additional cases that share peculiar clinical characteristics, pointing to diagnostic clues. All three cases presented as erythematous nodules developing distally to a proximal arteriovenous fistula (AVF). This presentation was identical to that of two published cases. A survey of all Belgian haemodialysis units during the period 2007–11 yields an estimated incidence of ∼0.9/10 000 patient-years. Although the source of M. chelonae remains unclear, this specific clinical presentation should be added to the listing of potential complications of an AVF and should be recognized, as it is fully treatable if diagnosed by culture and tissue biopsy.

Low reduction of HCV-RNA level at week 4 in HIV-1 infected patients with acute HCV Infection

The epidemic of acute Hepatitis C-virus infection (AHC) is an on-going issue, especially among MSM patients. Spontaneous HCV clearance rates have been estimated to be between 5-40%, with lower rates among HIV-1 co-infected patients. High rates of sustained virological response have been observed (60-80%) when patients are treated within 24 weeks of AHC diagnosis. Moreover, a spontaneous 2log reduction in HCV-RNA might be a good predictor of spontaneous HCV-RNA clearance in HIV-1 co-infected patients. The aim of this study is to analyse the incidence of 2-log-HCV-RNA spontaneous reduction in AHC in HIV-1 infected patients.