Rinaldo Focaccia Siciliano

Cytomegalovirus colitis in immunocompetent critically ill patients

OBJECTIVES Cytomegalovirus (CMV) is a ubiquitous virus and its reactivation may lead to CMV end-organ disease (CMV EOD) in immunocompromised patients and also in immunocompetent patients when they are critically ill. We aimed to investigate the frequency and the clinical features of proven CMV EOD in previously non-immunosuppressed patients admitted to our institution. METHODS From January 2000 to March 2013, the records of all patients with a histopathological diagnosis of CMV EOD at our teaching hospital were reviewed retrospectively. CMV EOD was diagnosed histologically by the identification of true cytomegalic viral inclusion involving endothelial, stromal, and/or epithelial cells on hematoxylin and eosin staining, and was subsequently confirmed by immunohistochemistry using specific antibody against CMV antigens. Immunocompromised patients were excluded. RESULTS CMV EOD manifesting as colitis was diagnosed in 14 previously immunocompetent intensive care unit (ICU) patients. The mean age of the patients was 64 years. All had co-morbidities and developed shock before CMV EOD. The major manifestation was gastrointestinal bleeding. The in-hospital mortality rate was 71.4% despite specific treatment with ganciclovir. CONCLUSIONS Despite being a rare condition, lower gastrointestinal bleeding in this profile of ICU patients could be the clinical manifestation of CMV colitis, and intensivists should be alert to this condition.

Infective endocarditis due to Bartonella spp. and Coxiella burnetii: experience at a cardiology hospital in Sao Paulo, Brazil.

Abstract:  Bartonella spp. and Coxiella burnetii are recognized as causative agents of blood culture–negative endocarditis (BCNE) in humans and there are no studies of their occurrences in Brazil. The purpose of this study is to investigate Bartonella spp. and C. burnetii as a causative agent of culture‐negative endocarditis patients at a cardiology hospital in São Paulo, Brazil. From January 2004 to December 2004 patients with a diagnosis of endocarditis at our Institute were identified and recorded prospectively. They were considered to have possible or definite endocarditis according to the modified Duke criteria. Those with blood culture–negative were tested serologically using the indirect immunofluorescent assay (IFA) for Bartonella henselae, B. quintana, and C. burnetii. IFA‐IgG titers >800 for Bartonella spp. and C. burnetii were considered positive. A total of 61 patients with endocarditis diagnosis were evaluated, 17 (27%) were culture‐negative. Two have had IgG titer greater than 800 (≥3,200) against Bartonella spp. and one against C. burnetii (phase I and II≥6,400). Those with Bartonella‐induced endocarditis had a fatal disease. Necropsy showed calcifications and extensive destruction of the valve tissue, which is diffusely infiltrated with mononuclear inflammatory cells predominantly by foamy macrophages. The patient with C. burnetii endocarditis received specific antibiotic therapy. Reports of infective endocartitis due to Bartonella spp. and C. burnetii in Brazil reveal the importance of investigating the infectious agents in culture‐negative endocarditis.

Endocardite por Coxiella burnetii (febre Q): doença rara ou pouco diagnosticada? Relato de caso

Q fever is a zoonosis of worldwide distribution that is caused by Coxiella burnetii. However, reports of this disease in Brazil are rare. Seroepidemiological studies have shown relatively high frequencies of antibodies against Coxiella burnetii in populations with occupational exposure. In humans, it can be manifested clinically as acute or chronic disease. Endocarditis is the most frequent chronic form of Q fever and the form with the greatest morbidity and mortality. We report a severe case of endocarditis due to Coxiella burnetii acquired in Brazil that had a fatal outcome, despite specific antibiotic therapy and valve surgery treatment.

Validated Risk Score for Predicting 6‐Month Mortality in Infective Endocarditis

Background Host factors and complications have been associated with higher mortality in infective endocarditis (IE). We sought to develop and validate a model of clinical characteristics to predict 6‐month mortality in IE. Methods and Results Using a large multinational prospective registry of definite IE (International Collaboration on Endocarditis [ICE]–Prospective Cohort Study [PCS], 2000–2006, n=4049), a model to predict 6‐month survival was developed by Cox proportional hazards modeling with inverse probability weighting for surgery treatment and was internally validated by the bootstrapping method. This model was externally validated in an independent prospective registry (ICE‐PLUS, 2008–2012, n=1197). The 6‐month mortality was 971 of 4049 (24.0%) in the ICE‐PCS cohort and 342 of 1197 (28.6%) in the ICE‐PLUS cohort. Surgery during the index hospitalization was performed in 48.1% and 54.0% of the cohorts, respectively. In the derivation model, variables related to host factors (age, dialysis), IE characteristics (prosthetic or nosocomial IE, causative organism, left‐sided valve vegetation), and IE complications (severe heart failure, stroke, paravalvular complication, and persistent bacteremia) were independently associated with 6‐month mortality, and surgery was associated with a lower risk of mortality (Harrells C statistic 0.715). In the validation model, these variables had similar hazard ratios (Harrells C statistic 0.682), with a similar, independent benefit of surgery (hazard ratio 0.74, 95% CI 0.62–0.89). A simplified risk model was developed by weight adjustment of these variables. Conclusions Six‐month mortality after IE is ≈25% and is predicted by host factors, IE characteristics, and IE complications. Surgery during the index hospitalization is associated with lower mortality but is performed less frequently in the highest risk patients. A simplified risk model may be used to identify specific risk subgroups in IE.

Case series of infective endocarditis caused by Granulicatella species.

BACKGROUND Nutritionally variant streptococci (NVS) are Gram-positive cocci characterized by their dependence on pyridoxal or cysteine supplementation for growth in standard blood culture media. They are responsible for severe infections in immunocompetent and immunosuppressed hosts, including infective endocarditis (IE). NVS have been divided into two different genera, Granulicatella and Abiotrophia. METHODS We report four cases of IE caused by Granulicatella species, including clinical presentation, echocardiographic characteristics, treatments received, and outcomes. We also performed a literature search for previously reported cases of IE caused by Granulicatella species to better characterize this condition. RESULTS A total of 29 cases of Granulicatella endocarditis were analyzed, including the four newly reported cases. The aortic (44%) and mitral (38%) valves were those most commonly affected. Multivalvular involvement was observed in 13% of cases. The mean vegetation length was 16mm. Complications were frequent, including heart failure (30%), embolism (30%), and perivalvular abscess (11%). The most frequent antibiotic regimen (85%) was penicillin or one of its derivatives plus gentamicin. The mortality rate was 17%. CONCLUSIONS Endocarditis due to Granulicatella species is a rare and severe condition. Complications are frequent despite the use of appropriate antibiotic regimens.

Toxoplasma gondii Myocarditis after Adult Heart Transplantation: Successful Prophylaxis with Pyrimethamine

Toxoplasma gondii primary infection/reactivation after solid organ transplantation is a serious complication, due to the high mortality rate following disseminated disease. We performed a retrospective study of all cases of T. gondii infections in 436 adult patients who had received an orthotopic cardiac transplant at our Institution from May 1968 to January 2011. Six patients (1.3%) developed T. gondii infection/reactivation in the post-operative period. All infections/reactivations occurred before 1996, when no standardized toxoplasmosis prophylactic regimen or co-trimoxazole prophylaxis was used. Starting with the 112th heart transplant, oral pyrimethamine 75 mg/day was used for seronegative transplant recipients whose donors were seropositive or unknown. Two patients (33.3%) presented with disseminated toxoplasmosis infection, and all patients (100%) had myocarditis. Five patients (83.3%) were seronegative before transplant and one patient did not have pre-transplant serology available. Median time for infection onset was 131 days following transplantation. Three patients (50%) died due to toxoplasmosis infection. After 1996, we did not observe any additional cases of T. gondii infection/reactivation. In conclusion, toxoplasmosis in heart allographs was more frequent among seronegative heart recipients, and oral pyrimethamine was highly effective for the prevention of T. gondii infection in this population.

Evaluation of a rapid dipstick test, Malar-CheckTM, for the diagnosis of Plasmodium falciparum malaria in Brazil

The present study was carried out to evaluate the Malar-Check trade mark Pf test, an immunochromatographic assay that detects Plasmodium falciparum Histidine Rich Protein II, does not require equipment, and is easy and rapid to perform. In dilution assays performed to test sensitivity against known parasite density, Malar-Check were compared with thick blood smear (TBS), the gold standard for diagnosis. Palo Alto isolate or P. falciparum blood from patients with different parasitemias was used. The average cut-off points for each technique in three independent experiments were 12 and 71 parasites/mm3 (TBS and Malar-Check, respectively). In the field assays, samples were collected from patients with fever who visited endemic regions. Compared to TBS, Malar-Check yielded true-positive results in 38 patients, false-positive results in 3, true-negative results in 23, and false-negative result in 1. Malar-Check performed with samples from falciparum-infected patients after treatment showed persistence of antigen up to 30 days. Malar-Check should aid the diagnosis of P. falciparum in remote areas and improve routine diagnosis even when microscopy is available. Previous P. falciparum infection, which can determine a false-positive test in cured individuals, should be considered. The prompt results obtained with the Malar-Check for early diagnosis could avoid disease evolution to severe cases.

Bartonella spp. and Coxiella burnetii Associated with Community-Acquired, Culture-Negative Endocarditis, Brazil.

We evaluated culture-negative, community-acquired endocarditis by using indirect immunofluorescent assays and molecular analyses for Bartonella spp. and Coxiella burnetii and found a prevalence of 19.6% and 7.8%, respectively. Our findings reinforce the need to study these organisms in patients with culture-negative, community-acquired endocarditis, especially B. henselae in cat owners.

Community-acquired culture-negative endocarditis: clinical characteristics and risk factors for mortality

OBJECTIVES We studied the clinical characteristics, in-hospital mortality, and long-term prognosis of patients with culture-negative endocarditis. METHODS In total, 221 episodes of definite endocarditis were studied (2004-2009). We compared the clinical, laboratory, and echocardiography characteristics and the survival rates of patients with culture-negative and culture-positive endocarditis. Survival after hospital discharge was evaluated using the Kaplan-Meier method and coefficient of mortality comparisons. RESULTS Culture-negative endocarditis occurred in 51/221 (23.1%) episodes. Compared with the culture-positive endocarditis patients, the time elapsed between admission and initiation of antibiotic therapy was longer in patients with culture-negative endocarditis (p<0.001), and these patients also had lower C-reactive protein levels at admission (p<0.001). In-hospital mortality rates were not different between culture-negative and culture-positive patients. After hospital discharge, there was also no significant difference between groups in survival curves (p=0.471). Severe sepsis (adjusted prevalence ratio 3.32, p=0.010) and diabetes mellitus (adjusted prevalence ratio 2.32, p=0.009) were independently associated with in-hospital death in culture-negative patients. CONCLUSIONS Culture-negative endocarditis patients presented with lower levels of C-reactive protein at admission and required more time for initiation of antibiotic therapy, although there was no difference in in-hospital mortality or long-term survival between culture-negative and culture-positive endocarditis patients. Diabetes mellitus and severe sepsis were associated with in-hospital death in patients with culture-negative endocarditis.

Bacteroides fragilis endocarditis: a case report and review of literature

Endocarditis due to Bacteroides fragilis is a rare disorder. This article describes a case of Bacteroides fragilis endocarditis associated with portal and superior mesenteric venous thrombosis in a patient without preexisting valvular heart disease and review the cases of endocarditis due to this anaerobic bacterium in medical literature since 1980.