1/6. Recurrent embolism in the course of marantic endocarditis.Marantic or nonbacterial thrombotic endocarditis (NBTE) associated with systemic embolism is usually a complication of advanced or terminal malignancies. We report on the case of a 46-year-old woman in whom nonbacterial thrombotic endocarditis (NBTE)-related cerebral embolism was the first clinical sign of ovarian neoplasm, which was diagnosed after cardiac surgery. Marantic endocarditis should alert the physician to make every effort to diagnose the possible background of this clinical phenomenon. Early identification of NBTE, treatment of the underlying disease, and the associated coagulopathy could possibly prevent cardiac surgery.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/6. Increased risk of neisserial infections in systemic lupus erythematosus.survival in systemic lupus erythamatosus (SLE) continues to improve because of better ancillary care, earlier diagnosis, and earlier treatment. However, infection remains a leading cause of morbidity and mortality in this disease. Although corticosteroids and immunosuppresives increase the risk of opportunistic infection, the SLE patient is still most at risk from common bacterial pathogens. As the prototypic immune-complex disease, patients with active SLE have low circulating complement as well as a reticuloendothelial system (RES) saturated with immune complexes. It seems intuitive that SLE patients should be most at risk for organisms dependent for their removal on the RES or complement for opsonization or bacteriolysis. The current series presents four patients with SLE and disseminated neisseria infection and brings to 14 the number of patients in the literature with disseminated neisserial infection. They are typically young, female, with renal disease, and either congenital or acquired hypocomplementemia, and may present with all features of a lupus flare. Surprisingly, they are not all on corticosteroids or immunosuppressives and have some features that are unusual for non-SLE patients with these infections. There seems to be an over-representation of Nisseria meningitidis (despite potential reporting bias), and there ironically may be better tolerance with fewer fulminant complications in patients who have complement deficiencies. The best approach for the physician treating SLE is to immunize all SLE patients with available bacterial vaccines to N meningitidis and streptococcus pneumonia, have a low threshold of suspicion for the diagnosis of disseminated neisserial or other encapsulated bacterial infection in the SLE patient who is sick, and to treat empirically with third generation cephalosporins after appropriate cultures.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/6. Invasive aspergillus infections complicating coronary artery bypass grafting.Endovascular infection with aspergillus species results in unacceptably high mortality of greater than 80% in most series. Failure to recognize the infection early during its clinical course contributes to its formidable lethality. blood cultures almost never reveal organisms, as in our Cases 1 and 2. When considering a patient with fever, changing murmur, major systemic emboli, or splenomegaly, and with blood cultures negative for organisms months or even years after cardiac surgery, therefore, the physician should maintain a high index of suspicion for fungal endocarditis. The best opportunity to establish the diagnosis antemortem rests in careful histopathologic and microbiologic examination of infected emboli and vegetations. Most authors agree that a combined approach employing early valve replacement and aggressive antifungal chemotherapy with amphotericin b and perhaps flucytosine or rifampin represents the best option for treatment of endovascular aspergillus infections.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/6. Dental treatment and management of a patient with a prosthetic heart valve.The american heart association committee recognizes that their regimens do not cover all situations. Each patient should be evaluated individually. The necessity for parenteral therapy or oral erythromycin to continue for 48 hours after all dental procedures should be reevaluated on a case-by-case basis. On the other hand, if the dental manipulation involves an infected site, perhaps antibiotic therapy should be continued until signs of the inflammation subside. dentists and physicians must use their clinical judgement in prescribing antibiotics. However, as Kaye proposed, any deviation in prescribing antibiotics should be in the direction of higher doses or more effective antibiotics. In addition, practitioners must provide adequate patient education and follow-up. Unfortunately, a negligent dentist, a physician giving poor or inadequate advice, or a patient not following instructions may turn a simple dental procedure into a life-threatening situation and potential tragedy.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
5/6. Cerebral embolism in cancer patients.Sudden neurological deterioration suggesting embolism in a patient with a history of cancer should alert the physician to the possibility of a non-metastatic, and therefore potentially reversible, cause of cerebral embolism before cerebral metastasis is implicated. During a four year period, we have observed eight cases of acute cerebral embolism among 3000 cancer patients seen in a department of medical oncology. Five patients had features post mortem of non-bacterial thrombotic endocarditis, and in one, the diagnosis had been made antemortem, but treatment with heparin did not prevent further emboli. Two patients had radiation related carotid vascular disease, and one patient post lymphangiographic embolism. The literature reporting these uncommon causes of cerebral embolism is reviewed. Post-lymphangiographic embolism carries a uniformly good prognosis. In selected cases of post-irradiation cerebral embolism, surgical intervention may prevent a neurological catastrophe. Non-bacterial thrombotic endocarditis and mucin embolism are of uncertain aetiology and natural history; long-term survival is uncommon, and treatment does not appear to influence the clinical course or outcome.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/6. An outbreak of candida parapsilosis prosthetic valve endocarditis.candida parapsilosis, an important nosocomial pathogen and the most common species of candida found on the hands of health care workers, is a rare cause of prosthetic valve endocarditis (PVE). From March through June 1994, four cases of C. parapsilosis PVE were diagnosed at a 400-bed community hospital. The mean time to presentation after valve replacement surgery was 148 days (range, 20 to 345). Three of the four patients died of complications of PVE. Multiple environmental cultures were performed, and only one was positive for C. parapsilosis. Cultures from the bypass pump, cell saver, cardioplegia solution, and subsequent valves were all negative. All valve replacements were performed by the same operating room team. Interviews with the surgeon and physician assistant, the only personnel involved in all cases, revealed that their hypoallergenic gloves were subject to frequent tears during valve replacement procedures, often requiring several glove changes per procedure. hand cultures of personnel were obtained, and cultures from 20 individuals (26%) were positive for C. parapsilosis. hand cultures of the surgeon and physician assistant obtained 8 months after the last case had surgery were negative for yeasts. molecular typing of the 3 available case isolates, 14 epidemiologically unrelated patient isolates, 1 environmental isolate, and 20 hand isolates was performed by electrophoretic karyotyping and restriction endonuclease analysis of genomic dna using restriction enzymes BssHII and EagI followed by pulsed field gel electrophoresis. The three case isolates were identical by restriction endonuclease analysis of genomic dna, and two of the three shared the same electrophoretic karyotyping profile. The remaining patient, environmental, and hand isolates represented 29 different dna types and were distinctly different from the case isolates. All of the isolates tested were susceptible to amphotericin b, 5FC, fluconazole, and itraconazole. The circumstantial evidence suggests the probability of glove tears during valve replacement surgery and subsequent transmission of C. parapsilosis to patients.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |