Rafael Perelló

Diagnostic and management of spontaneous rectus sheath hematoma

BACKGROUND Spontaneous rectus sheath hematoma is an uncommon and often misdiagnosed cause of abdominal pain. The aim of this study is to describe our experience in their management. METHODS Retrospective analysis of the characteristics and outcomes of the spontaneous rectus sheath hematomas diagnosed over the last 12years was conducted. RESULTS 24 patients were included (66% women; mean age: 74years; range: 54-87). All cases presented predisposing factors mainly anticoagulant therapy in 21 (87.5%) patients, hypertension in 19 (79.1%) and abdominal surgery in 12 (50%) cases. Eighteen (75%) referred triggering factors like coughing being the most common one, present in 17 (70.8%) patients. The main clinical findings were abdominal pain in 21 (87.5%) cases and the existence of an abdominal mass in 20 (83.3%). The diagnosis was confirmed by abdominal ultrasonography and/or computerized tomography in 23 (95.8%) patients. Nineteen cases (79.1%) responded to conservative management while 5 (20.8%) required interventional treatment, which consisted in an arteriography with selective embolization of the epigastric arteries in all cases. Four (80%) of the patients needing interventional treatment were receiving low molecular weight heparin. Nine (37.5%) patients developed hypovolemic shock and 1 (4%) died. CONCLUSIONS Spontaneous rectus sheath hematomas should be considered in the differential diagnosis of abdominal pain, particularly in elderly women under anticoagulant therapy with onset of symptoms after a bout of cough. Most cases respond to conservative management, although those related to low molecular weight heparin might require interventional treatment; arteriography with selective embolization of the epigastric arteries is the first therapeutic option.

Clinical presentation of acute coronary syndrome in HIV infected adults: A retrospective analysis of a prospectively collected cohort

OBJECTIVES To compare clinical presentation and short-term prognosis of acute coronary syndrome (ACS) in HIV-infected and uninfected adults. DESIGN Retrospective analysis of a prospectively collected cohort. METHODS HIV-infected patients with myocardial infarction or unstable angina were identified by clinical history and specific characteristics of HIV infection were consecutively registered. Surviving patients were followed for at least one month after discharge. Risk factors for cardiovascular disease, clinical symptoms at admission, type of ACS, delivery of care, and factors associated with prognosis were compared between HIV-infected and uninfected adults. RESULTS Among 627 patients included, 44 (7%) were HIV-infected patients. HIV-infected patients were younger, more frequently men, and had higher prevalence of cardiovascular risk factors than uninfected patients. HIV-infected patients persisted frequently with less pain at Emergency Department (ED) (34% vs 82%, P<0.001) and complained of dyspnea (2% vs 15%, P<0.05) persisted in respect to HIV-uninfected patients. ST-elevation myocardial infarction was the most frequent ACS in HIV-infected patients (59% vs 24%) whereas non-ST-elevation myocardial infarction (23% vs 38%) and unstable angina (18% vs 38%) were the predominant ones in uninfected patients (P<0.001). Catheterism was performed more commonly in HIV-infected patients (75% vs 62%, P<0.01) and similarly admitted in the coronary care unit (38% vs 41%, P=0.81). The evolution was similar in both groups. When HIV-infected patients were matched by age and sex with a subgroup of 88 HIV-uninfected patients, most of the differences disappeared. CONCLUSIONS HIV-infected adults presenting with ACS are younger and have fewer symptoms than uninfected. Despite having a more established disease, short-term prognosis is similar.

Association between mannose-binding lectin deficiency and septic shock following acute pyelonephritis due to Escherichia coli.

ABSTRACT Structural and promoter MBL2 gene polymorphisms responsible for low MBL levels are associated with increased risk of infection. The objective of this study was to assess the possible association between polymorphisms of the MBL2 gene and the incidence of septic shock and bacteremia in patients with acute pyelonephritis due to Escherichia coli. The study included 62 female patients with acute pyelonephritis due to E. coli who required hospital admission, as well as 133 healthy control subjects. Six single-nucleotide polymorphisms (−550 G/C, −221 C/G, +4 C/T, codon 52 CGT/TGT, codon 54 GGC/GAC, and codon 57 GGA/GAA) in the MBL2 gene were genotyped by using a sequence-based typing technique. No significant differences were observed in the frequencies for low-expression MBL2 genotypes (O/O and LXA/O) between patients with acute pyelonephritis and healthy controls. Patients with acute pyelonephritis and septic shock had a higher incidence of low-expression MBL2 genotypes than patients with acute pyelonephritis without septic shock (odds ratio = 9.019, 95% confidence interval = 1.23 to 65.93; P = 0.03). No association was found between bacteremic acute pyelonephritis and low-expression MBL2 genotypes. We found that low-expression MBL2 genotypes predispose to septic shock but not to bacteremia in patients with E. coli-induced acute pyelonephritis. Determination of MBL2 polymorphisms could be useful for assessing the risk of septic shock in women undergoing acute pyelonephritis.

Predicting bacteremic pneumonia in HIV-1–infected patients consulting the ED

INTRODUCTION HIV-1-infected patients have higher incidence of community-acquired pneumonia (CAP) and risk of complications. Bacteremia has been associated with a higher risk of complications in such patients. We investigated factors associated with bacteremia in HIV-1-infected patients with CAP presenting at the emergency department. METHODS We included HIV-1-infected patients with CAP for 3 years (March 2005-February 2008). Only patients in whom blood cultures were performed were finally included. Clinical data (age; sex; CD4(+) count; serum HIV viral load; previous or current intravenous drug use and antiretroviral treatment; systolic blood pressure; and cardiac and respiratory rates), analytical data (leukocyte count, arterial oxygen content, C-reactive protein value, and urgent Streptococcus pneumoniae and Legionella spp antigen urine detection), and APACHE-II (Acute Physiology and Chronic Health Evaluation) score were compiled. The need for intensive care unit admission, mechanical ventilation, mortality, and for patients finally discharged, duration of admission were retrospectively obtained from the clinical history. A multivariate analysis using logistic regression was performed to find independent predictors of bacteremia. RESULTS We diagnosed 129 HIV-1-infected patients with CAP. Blood cultures were performed in 118 cases (91%). Bacteremia was present in 28 (24%). Independent predictors of bacteremia were the detection of S pneumoniae antigen in urine (odds ratio, 9.0; 95% confidence interval, 1.9-42.0) and the absence of current antiretroviral treatment (odds ratio, 7.1; 95% confidence interval, 1.4-33.3). In-hospital mortality was higher in patients with bacteremia (15% vs 0%). CONCLUSION HIV-1-infected patients with CAP who are not on current antiretroviral therapy and have positive S pneumoniae antigenuria are at increased risk of having bacteremia. Bacteremic patients have a poor outcome.

Is eosinopenia a reliable marker of sepsis

We have read with interest the article by Abidi and colleagues [1] in which the authors point out that eosinopenia could be useful to differentiate between noninfection and infection in patients recently admitted to an intensive care unit (ICU). The association of eosinopenia with infections is not new and has been described previously [2]. To test this hypothesis, we reviewed 191 patients (age >18 years, with a minimum ICU stay of 24 hours) admitted to the medical ICU of our hospital. We exuded HIV-infected patients and those with hematological malignancies. Total leukocyte and eosinophil count (EC) were measured at ICU admission. The results are shown in Table ​Table1.1. Although the EC was lower and the proportion of patients with eosinopenia (<40 cells/ml) was higher in the noninfectious systemic inflammatory response syndrome (SIRS) group compared with the infectious SIRS group, these differences were not statistically significant. Therefore, the EC was not useful to distinguish between infection and noninfection. Although one limitation of our study was the absence of a non-SIRS group, the EC of our noninfectious SIRS group was similar to the EC found in the non-SIRS group in the study by Abidi and colleagues [1]. Another study failed to observe an association between eosinopenia and bacteremia [3]. Table 1 Baseline characteristics of the ICU patients included in the study In conclusion, eosinopenia was not a reliable marker of infection. Other analytical parameters, such as C-reactive protein, have demonstrated to be helpful not only for the diagnosis of infection but also as a marker of severity of organ dysfunction in sepsis [4].

Genotypes Coding for Low Serum Levels of Mannose-Binding Lectin Are Underrepresented among Individuals Suffering from Noninfectious Systemic Inflammatory Response Syndrome

ABSTRACT Gene polymorphisms, giving rise to low serum levels of mannose-binding lectin (MBL) or MBL-associated protease 2 (MASP2), have been associated with an increased risk of infections. The objective of this study was to assess the outcome of intensive care unit (ICU) patients with systemic inflammatory response syndrome (SIRS) regarding the existence of functionally relevant MBL2 and MASP2 gene polymorphisms. The study included 243 ICU patients with SIRS admitted to our hospital, as well as 104 healthy control subjects. MBL2 and MASP2 single nucleotide polymorphisms were genotyped using a sequence-based typing technique. No differences were observed regarding the frequencies of low-MBL genotypes (O/O and XA/O) and MASP2 polymorphisms between patients with SIRS and healthy controls. Interestingly, ICU patients with a noninfectious SIRS had a lower frequency for low-MBL genotypes and a higher frequency for high-MBL genotypes (A/A and A/XA) than either ICU patients with an infectious SIRS or healthy controls. The existence of low- or /high-MBL genotypes or a MASP2 polymorphism had no impact on the mortality rates of the included patients. The presence of high-MBL-producing genotypes in patients with a noninfectious insult is a risk factor for SIRS and ICU admission.

Implicación de los virus respiratorios en la neumonía adquirida en la comunidad en pacientes infectados por el virus de la inmunodeficiencia humana

El papel de los virus respiratorios (VR) en el paciente infectado por el virus de la inmunodeficiencia humana (VIH) que presenta una neumonía adquirida en la comunidad (NAC) es poco conocido. El objetivo de este estudio es determinar la implicación de los VR en la NAC del paciente VIH mediante un estudio prospectivo de 3 años en un hospital terciario. Se diagnosticaron 67 neumonías, y se detectaron VR en 14, en 8 como únicos microorganismos aislados. Los pacientes con NAC y VR evolucionaron de forma similar a los pacientes con NAC. La infección por VR en pacientes VIH y NAC no supuso un factor de mal pronóstico evolutivo. The role of respiratory viruses in community-acquired pneumonia (CAP) in human immunodeficiency virus (HIV)-infected patients has not been extensively investigated. The objective was to study the implication of respiratory viruses in HIV patients with CAP, through a prospective, three-year study in a third-level hospital. Respiratory viruses were implicated in 14 of the 67 cases of CAP diagnosed and were the only microorganism isolated in 8 of them. Evolution of the disease was similar in patients with CAP associated with respiratory virus infection and those with CAP alone. Respiratory virus infection in HIV-infected patients with CAP is not associated with a poorer prognosis.

Urgent pneumococcal urinary antigen, importance in the diagnosis of acquired pneumonia in Hiv-1 patients

The aim of our study was to determine the usefulness of pneumococcal urinary antigen (UA) collected in the emergency department (ED) for the microbiologic diagnosis of community-acquired pneumonia (CAP) in HIV patients and to compare it with other diagnostic tests. Prospective study from 1 January 2007 to 31 December 2008 included HIV-infected patients admitted at the ED with respiratory symptoms and who were diagnosed of CAP. UA, two blood cultures and sputum sample for culture determination were collected from every patient. Sixty-four patients were included. The mean age was 42 years. A total of 31 (48%) UA tests, 12 (19%) blood cultures and 21 (33%) sputum cultures tested positive. A microbiological diagnosis was obtained in 38 (59%) cases. Pneumococcal pneumonia was diagnosed in 32 cases. The statistical analysis showed that the test with best performance was the UA, both in relation to blood and sputum cultures (P<0.05). Two patients died during hospitalization (series mortality of 3%). In conclusion, given its good diagnostic performance, UA should be requested in the ED for the aetiological diagnosis of CAP.

Detection of human cytomegalovirus in bronchoalveolar lavage of intensive care unit patients

The seroprevalence of human cytomegalovirus (CMV) is very high worldwide [1, 2] and the spectrum of disease caused by it ranges from an asymptomatic state to a mononucleosis-like syndrome to severe diseases such as pneumonia, retinitis or gastrointestinal infection. The most severe disease occurs in congenital infection and in immunosuppressed patients, in whom the virus acts as an opportunistic pathogen. However, the role of CMV in other populations is less clear and is controversial [3]. Some studies in critical patients describe a relationship between CMV and increased mortality rates, longer length of stay and prolonged need for mechanical ventilation [3–5]. The incidence of active CMV infection depends on the diagnostic method used. Several epidemiological studies and systematic reviews have assessed the incidence of CMV infection in mechanically ventilated, critically ill patients, finding values ranging from 0–36% [5–7]. In this study, we aimed to assess the incidence, clinical characteristics, risk factors and outcomes for intensive care unit (ICU) patients with CMV detection by bronchoalveolar lavage (BAL). What is the role of cytomegalovirus (CMV) in ICU patients? http://ow.ly/GeM130holtF

Changes in the etiology, incidence and prognosis of acute lower respiratory track infections in human immunodeficiency virus patients

AIM To describe the incidence, the changes in the etiology and the prognosis of lower respiratory tract infection (LRTI) in HIV infected patients, presenting by the first time to the Emergency Department (ED), during years 2000-2010. STUDY DESIGN Prospective collection of data. METHODS Data were collected on the first visit of HIV-infected patients at our ED due to a LRTI, (defined according to the criteria of the European Respiratory Society), between 1/1/2000 and 31/12/2010. A series of epidemiological and laboratory variables as well as the need for admission to the intensive care unit (ICU). LRTI etiology were also collected. The influence ofthe mentioned variables on 30-day mortality were analyzed. RESULTS One hundred thirty one patients were included. LRTI represented 27% of visits to the ED by HIV-infected patients. Mean age was 39±9 years. 72% of patients were males. 18% required admission to the ICU. The most frequent LRTI was pneumonia by P. jiroveci in 35 cases, bacterial penumonia in 27 and pulmonary tuberculosis in 20. LRTI incidence gradually reduced significantly over time from 6.13 × 1000 patients/year in year 2000 to 0.23 × 1000 patients/year in 2010 (p<0.05). Overall mortality was 14%. Logistic regression analysis showed that admission to ICU (p<0.004) and viral load (p<0.029) were independent variables predicting mortality. CONCLUSION LRTI is a pathology with a decreasing incidence, probably related to the widespread utilization increased of HAART regimens. lts etiology has also been changing, but with a non negligible mortality, mostly when ICU admission was required.