Intravenous Ceftriaxone Research Articles

A Case Series on Neuroborreliosis- An Emerging Infection in India

Lyme disease is a zoonotic disease spread by the bite of Ixodes ticks. These ticks are known to be found in wooded or grassy areas. The disease manifestations can be divided into early Lyme disease and late Lyme disease. The manifestations of late Lyme disease may include arthritis, cranial nerve palsies, short-term memory deficits and Lyme carditis. The disease is diagnosed by a two-step process of Enzyme immunoassay followed by Western blot Test. Disseminated disease is treated with Intravenous (IV) ceftriaxone, cefotaxime or penicillin G, or a combination of oral and IV regimens or in some cases, only oral drugs for up to 28 days. Lyme disease is endemic in temperate regions, especially in America. However, over the years the disease has been reported from various countries of Asia including in India, where there have been sporadic cases. Hereby, the author presents three paediatric cases with varied presentations. The neurological symptoms ranged from Lower Motor Neuron (LMN) facial nerve palsy to acute encephalitis. One patient also had non-erosive arthritis.

Pyrexia of unknown origin in a 1-year-old child: How far should we go? A case report

Introduction: Pyrexia of unknown origin (PUO) still remains a challenge in paediatric practice. Appropriate history, physical examination, and exhaustive investigations are crucial in managing cases of PUO. Case Presentation: UU, was a 1-year-old female, who was seen at our facility on 16 January 2020, with a 4-day history of fever. Fever was high grade and intermittent. Examination revealed pyrexia of 38°c and no other remarkable findings. Lassa fever virus serology, hepatitis B surface antigen, hepatitis C surface antigen, C-reactive protein, erythrocyte sedimentation rate, full blood count, blood culture (with Bactec), malarial parasite, Mantoux, and CXR were all requested. Results of all these investigations were negative. Echocardiography done showed a 0.23 cm² vegetation at the septal leaflet of the tricuspid valve. A diagnosis of infective endocarditis was made and intravenous vancomycin, ceftriaxone, and metronidazole were commenced. Weekly urinalysis and serum electrolyte urea and creatinine monitoring were documented. After a 3-week course of intravenous antibiotics, patient still had fever with temperature higher than 38°c. A diagnosis of PUO was made and a follow-up plan was to do a bone marrow aspiration to rule out leukaemia and serology to rule out connective tissue disease. Conclusion: In managing a child with PUO, detailed history, appropriate physical examination and exhaustive investigations should be done. This is crucial in that even if diagnosis is not reached, several causes of PUO could have been ruled out.

Antibiotic Prophylaxis and Treatment in Early Cardiac Implantable Electronic Devices Infection.

Background:Cardiac implantable electronic devices – PM, ICD, and CRTs- are well-proven life-sustaining and the ultimate destination for many heart conditions. Based on scientific evidence, there is a worldwide incremental increase in CIED implantations numbers.Objective:Early infection of cardiac implantable electronic devices (CIED)– pacemaker (PM), implantable cardioverter-defibrillator (ICD), and cardiac resynchronization therapy (CRT)– is a growing health challenge. We examined the effectiveness of antibiotic prophylaxis and treatment of early infection of CIED in a single center.Methods:This is a retrospective, single-center observational study. Data were collected from patients’ records from July 2017-July, 2019. All Patients received intravenous ceftriaxone 2gm before incision, Gentamicin 120mg pocket irrigation, and oral Amoxicillin/Clavulanate for 5 days post-implantation.Results:A 639 consecutive CIED implantations – PM (n=474, mean age, 64yr, female=49%), ICD (n=106, mean age 56yr, female=17%) and CRT (n=59, mean age, 54yr, female=20%)- were performed over 3years. The incidence of early infection was 1.9% (12 cases), female=41%. PM=5/474, ICD=5/106, and CRT=2/59. Three out of the 12 patients had total device explant due to pocket abscess; one PM had a generator changed; one ICD who had a pneumothorax, and the third one had reimplantation after ICD lead perforation. Nine cases were managed conservatively using saline dressing and oral Amoxicillin/Clavulanate, 3/9 patients developed a hematoma, 4/9 patients developed purulent suture line infection. None of them had infection recurrence on three months follow up.Conclusion:Early infection of CIED is a rare complication with multiple predisposing factors. Our protocol is reassurance and prompt initiation of management protocol to prevent and treat this issue’s sequences.

Fournier's gangrene: Presentation and predictors of mortality in Zaria, Nigeria.

Background:Fournier's gangrene is an infectious urological emergency with associated morbidity and varying rates of mortality in the world. Various predictors of mortality such as advancing age, Fournier's Gangrene Severity Index (FGSI), anatomical extent of the disease, or presence of risk factors have been studied in the literature, though with conflicting results.Aim:The aim of the study was to determine the presentation and predictors of mortality in our environment, Nigeria.Patients and Methods:A review of medical records of all the patients managed from April 2012 to December 2018 at a tertiary referral center in Nigeria was conducted. Data on clinical presentation, FGSI, management, and outcome were retrieved and analyzed.Statistical Analysis:Descriptive studies using mean and standard deviation were used for continuous variables, Fischer's exact test was used to compare categorical variables among survivors and nonsurvivors, and logistic regression analysis was used to describe the relationships of these variables with mortality.Results:The mean age of the 31 patients was 60 ± 12 years. All were men, with 9 (29.0%) patients without clinical evidence of immunosuppression or predisposing factor (idiopathic). Fourteen (45%) had documented evidence of immunosuppression. All the patients had a polymicrobial infection; however, Escherichia coli was the most common organism cultured seen in 26 (83.9%) patients. The initial empirical antibiotic regimen of choice was a combination of intravenous ceftriaxone and metronidazole in 26 (83.8%) patients and intravenous ciprofloxacin and metronidazole in 5 (16.1%) patients. Mortality was recorded in three patients representing a rate of 9.6%. Anatomical extent of the disease, anemia requiring blood transfusion, severity of infection, and FGSI were all found to be the statistically significant variable of mortality in these patients using the Fischer exact test. Furthermore, on regression analysis only the FGSI and blood transfusion were significant with P < 0.05.Conclusion:Fournier's gangrene is a disease of the older men with a higher mortality rate when the FGSI is >9 or anemia requiring blood transfusion is present.

Adjuvant use of combination of antibiotics in acute severe ulcerative colitis: A placebo controlled randomized trial

ABSTRACT Objectives Evaluation of a combination of antibiotics as an adjuvant therapy in acute severe ulcerative colitis (ASUC). Methods Patients with ASUC were randomized to either infusions of placebo or intravenous ceftriaxone and metronidazole in addition to standard care. Primary outcome was response on day three according to Oxford’s criteria. Secondary outcome measures included changes in partial Mayo score, CRP levels, fecal calprotectin (day three), and need for second-line therapy, hospital stay, and mortality (day 28). Results Fifty patients (25 in each group, median age: 33 years, 23 males) were included. The number of patients with fulminant disease in the antibiotic group were 16 (64%) as compared to 7 (28%) in the standard of care group. Complete response on day three was attained by 7 (28%) in the antibiotic and 6 (24%) standard of care group (p = 1.00). Three patients from the antibiotic group underwent colectomy and three received intravenous cyclosporine whereas four patients in the standard of care group received cyclosporine (p = 0.725). There was no significant difference in change in CRP, Partial Mayo score, and fecal calprotectin between the two groups on day three. Conclusion Combination of intravenous ceftriaxone and metronidazole did not improve outcomes in ASUC. Acronym: AAASUC trial Registration Number: CTRI/2019/03/018196 and NCT03794765

Oral Azithromycin Vs Intravenous Ceftriaxone in the Treatment of Enteric Fever: A Systematic Review and Meta-Analysis

Background: Typhoid fever, also known as enteric fever, is a severe systemic illness characterized by fever and gastrointestinal manifestations that commonly affects children and young adults. It is most prevalent in SouthCentral Asia, Southern Africa, and Southeast Asia. Alternative drugs for the treatment of enteric fever have been studied to decrease toxicity and increase compliance. Oral azithromycin has been proposed and is widely studied as a suitable treatment alternative. Objective: The objective of this study is to compare oral azithromycin with intravenous ceftriaxone in the treatment of uncomplicated typhoid fever in terms of cure, duration of fever, relapse, and adverse events. Methodology: A systematic review and meta-analysis were done with eligible studies taken from PUBMED, MEDLINE, and Cochrane Clinical Trial Registry. Six studies passed the eligibility criteria and were analyzed using Review Manager 5.3. Results: Azithromycin showed comparable results with ceftriaxone in terms of cure, duration of fever and adverse events. However, azithromycin proved superior in decreasing relapse. Conclusion: Azithromycin is comparable to ceftriaxone in the treatment of uncomplicated typhoid fever in terms of cure, duration of fever, and occurrence of adverse events. Azithromycin likewise had a lower incidence of relapse. Recommendations: We recommend conducting local trials in pediatric patients, to compare azithromycin with standard antibiotic regimen for typhoid fever, to help update local recommendations and expand choices for antibiotic use.

Fatal adenovirus meningoencephalitis in end stage renal disease patient

Background: Severe disseminated adenovirus infections that presented with severe pneumonia in respiratory failure, encephalitis or septicemic shock causes high mortality in immunocompromised patients. We reported a case ofadenovirus encephalitis in an end stage renal disease (ESRD) who presented with seizure, subsequently adenovirus DNA was detected from his cerebrospinal fluid with typical findings on electroencephalography (EEG). It highlights the need for consideration of adenovirus as cause of encephalitis. Case Description: A 66 y old gentleman with (ESRD) on regular hemodialysis was initially admitted to another hospital for 1w. He was found unconscious in the bathroom at home and subsequently developed tonic-clonic seizure prior to arrival to hospital. Patient had fever and productive cough for three days prior. On arrival to emergency department, he was intubated in view of low Glasgow coma scale (GCS) (E1V2M3). Neurological examination revealed normal tone. Contrast enhanced Computer Tomography (CT) of brain revealed multifocal old infarct with small right parieto-temporal scalp hematoma. Cerebrospinal fluid (CSF) showed high protein 871 ng/L and normal glucose ratio with elevated white cell count 10 cells/mm3 predominantly lymphocytes. CSF cryptococcal antigen and Indian Ink were negative and other cultures had no growth. He was treated as meningoencephalitis and started on intravenous ceftriaxone 2 g BD and IV acyclovir 250 mg OD Second lumbar puncture repeated on day 9 on transfer to our hospital of illness in view of no clinical improvement showed elevated opening pressure 22 cm H2O. CSF analysis revealed elevated protein 510 ng/L with adenovirus PCR was positive (4.5 log 10 DNA copies/ml). (EEG) revealed periodic lateralized epileptiform discharges. No other bacterial or fungal pathogen was identified s and tuberculous PCR was negative Intravenous cidofovir was initiated. However, his condition continued to deteriorate and succumbed 5 d following first dose of cidofovir (day 17 of hospitalisation). Discussion: This case highlights the need of consideration of adenovirus meningoencephalitis and illustrates the potential fatal disease in dialysis dependent renal disease patient. The initial diagnosis in this case is challenging as the initial clinical presentation is mimicking severe bacterial infection or septicaemia. Conclusion: Adenovirus meningoencephalitis is a rare but fatal manifestation of severe adenovirus infection with mortality rate up to 39%.

Primary meningococcal pericarditis presenting as acute coronary syndrome with angiographically confirmed obstructive lesions

Background: Primary meningococcal pericarditis (PMP) is defined as purulent pericarditis without clinical evidence of meningococcaemia, meningitis, or other foci of meningococcal infection. Meningococcal infections associated with ST segment elevation and raised cardiac enzymes mimicking acute myocardial infarction have been previously reported, but all of these cases had a normal coronary angiogram, which may indeed represent a diagnosis of myocarditis, especially when no endomyocardial biopsies had been conducted. We report a unique case of primary meningococcal pericarditis presenting as acute coronary syndrome with angiographically confirmed obstructive lesions. Case Description: A 68 y old gentleman, an ex-smoker with multiple comorbidities, presented with acute-onset chest pain. There was no fever, skin rashes or meningeal signs. Electrocardiogram revealed hyperacute T at leads V2 to V5 and ST elevation at leads V7 to V9. Bedside echocardiogram disclosed septal wall hypokinesia with a pericardial effusion. Cardiac catheterisation revealed triple-vessel disease with critical stenosing lesion in the mid left anterior descending artery. Plasma troponin I was elevated. 3 d later, patient developed new-onset fever with worsening pericardial effusion and signs of impending cardiac tamponade. Emergent pericardiocentesis yielded pericardial fluid with an exudative picture. Both pericardial fluid and blood culture grew Neisseria meningitidis W-135. Intravenous ceftriaxone 2 g 12 h was initiated. Post-exposure prophylaxis was given to all healthcare workers affected. In spite of appropriate antimicrobial therapy, patient further deteriorated and succumbed due to multiorgan failure. Discussion: Invasive meningococcal infections other than meningitis and meningococcaemia have not been reported in Malaysia before. Neisseria meningitidis W-135 infections in Malaysia are commonly associated with Hajj pilgrimage. PMP usually has a favourable outcome with appropriate and timely antimicrobial administration. However, it was not suspected initially in our case who had no infectious prodrome, history of Hajj pilgrimage or exposure to a known case of meningococcal infection. The infectious process probably acted as an inciting event for acute coronary syndrome secondary to increased coronary vascular resistance induced by inflammatory cytokines. Conclusion: Our case underscores the importance to include infective causes of pericarditis in the differential diagnosis of pericardial effusion in any patient presenting with acute coronary syndrome, especially high-risk groups such as elderly population, diabetics, and those with multiple comorbidities.

Amoebic liver abscess with lung involvement in paediatric

Background: There are few reports of amoebic liver abscess in children, and the disease is life-threatening. It can rupture into the pleura to cause acute respiratory distress. Pulmonary amoebiasis, the second most common extra-intestinal pattern of infection, is frequently associated with amoebic liver abscesses. Case Description: We reported a case of amoebic liver abscess with lung involvement in a 10 y old Malaysian boy who presented with prolonged fever, lethargy, diarrhea, and right hypochondriac pain. He was diagnosed with possible ruptured liver abscess. Intravenous Ceftriaxone and Metronidazole were commenced. No organism was isolated in Blood culture, and stool microscopic examination for ova and cyst was negative. Ultrasonography of abdomen revealed of peritoneal collection with amoebic liver abscess in the superolateral segment of right lobe of liver whereas ultrasonography of thoracic showed pleural effusion and collapsed consolidation of right lower lobe of lung. After two days of admission, he developed acute respiratory distress Abdominal and chest drainage were done. Pleural fluid microscopic examination revealed Trophozoite of Entamoeba histolytica. Patient responded well clinically after completed four ws of treatment of Metronidazole. Discussion: The role of microscopic stool examination is limited. In this case, only one sample of stool was sent, and a microscopic stool examination of the cyst was negative. In view of the difficulty in demonstrating the causative pathogen in a clinical specimen, serological methods play an important role in diagnosing amoebic liver abscess. If the patient had undergone drainage of the abscess surgically, the aspiration material could be sent for microscopic examination. In this case, the microscopic examination of pleural fluid revealed the trophozoite of Entamoeba histolytica. Ultrasonography is easy and very useful in making early diagnosis and treatment. Most uncomplicated amoebic liver abscesses can be treated successfully with amoebicidal drug therapy alone. However, such in this case, ruptured amoebic liver abscess with lung involvement, surgical drainage is needed. In this case, the patient was responded well after four ws of treatment of Metronidazole. Conclusion: A multidisciplinary approach, including a gastroenterologist, radiologist, surgeon, and laboratory, is crucial for early diagnosis and successful treatment of these curable infections to prevent further complications, which can compromise the patient's outcome.

Dual infection: Dengue fever with Legionella pneumonia complicated with acute kidney injury and rhabdomyolysis

Background: Concurrent infection of dengue fever with legionella pneumonia is relatively rare occurrence as there is no case report documented in literatures. Treating dengue fever with bacterial infection has been an emerging challenge for physician. Legionella pneumophila is a common, usually underreported and undiagnosed cause of community acquired pneumonia which can lead to significant morbidity and mortality. We present a case of previously healthy man diagnosed as dengue fever with legionella pneumonia complicated with severe acute respiratory distress syndrome, acute renal failure and rhabdomyolysis. Case Description: A 42 y old gentleman with underlying bronchial asthma presented to emergency department with three days history of fever, nonproductive cough for two d with shortness of breath and chest discomfort. He was febrile, tachypneic and tachycardic. His blood pressure was 150/80 mmHg and saturating at 95% on room air. Crepitations were present on the right lower zone. Reviews of other system unremarkable. His full blood count showed leucopenia with thrombocytopenia. His Urea and creatinine were high. Creatine kinase was tremendously high reaches 34000 U/L indicates rhabdomyolysis. Arterial blood gas showed type 1 respiratory failure. Chest xray revealed consolidation over right basal with right sided pleural effusion. His rapid dengue serology noted NS1 antigen positive and dengue PCR revealed dengue genotype 1. He was placed on mechanical ventilation as respiratory distress worsened with hypoxemia. Empirically intravenous ceftriaxone was given to cover for pneumonia. However, he was rapidly deteriorated into septic shock. Subsequently noted that Legionella pneumophila Urinary Antigen was positive. Thus, azithromycin was prescribed. He has improved dramatically over the next 48 h and became hemodynamically stable. Discussion: Legionnaires disease was diagnosed as the cause of the clinical spectrum described. Acute kidney injury and rhabdomyolysis gradually improved after azithromycin commencement. In this case as the patient had dengue fever with legionella pneumonia, the cause for pleural effusion became a challenging part for physician. Treatment with appropriate fluid resuscitation, antibiotics and various modes of mechanical ventilation in the intensive care unit were successful. Conclusion: The presentation of progressively worsening respiratory distress or sepsis with dengue fever should raise the treating physician's suspicion of concurrent infection to reduce dengue fever associated mortality.

A Rare Cause of Facial Paralysis in Children: A Case of Ramsay Hunt Syndrome

AbstractPeripheral facial paralysis in children can have many causes including trauma, otitis media, head and neck tumors, congenital anomalies, viral infections, as well as metabolic and genetic factors. One cause of peripheral facial paralysis is Ramsay Hunt syndrome (RHS), which is also known as herpes zoster oticus, affecting the seventh and eighth cranial nerves. It is characterized by inner ear dysfunction, periauricular pain, and peripheral facial paralysis accompanied by the presence of an erythematous vesicular rash around the ear pinna and outer ear canal or in the oral mucosa. RHS is very rare in children when compared with its prevalence in adults. A 13-year-old male with no prior medical history applied to the pediatric emergency department after having first developed a vesicular rash on the left ear pinna and pain around the left ear, which was followed 1 day later by the development of ipsilateral facial asymmetry. The patient was hospitalized and simultaneously started on 2 mg/kg/d methylprednisolone for 10 days (followed by a 15-day taper), 100 mg/kg/d intravenous ceftriaxone twice per day (stopped on day 10), 30 mg/kg/d intravenous acyclovir three times per day (stopped on day 21), ciprofloxacin ear drops, tobramycin eye drops, ointment, and artificial tear drops with eye patching. However, only a minimal improvement was observed in the patient's peripheral facial paralysis by day 21. When compared with the prevalence in adults, RHS is very rare in children, which is why reports of pediatric RHS are limited in the literature. Therefore, additional studies are needed to provide information about the pathophysiology, diagnosis, and treatment of pediatric RHS.

Spontaneous Pan-Vertebral Epidural Abscesses Caused by Streptococcus Intermedius in an Immunocompetent Patient

Spinal epidural abscess (SEA) is a rarely reported condition. Here, we present a unique case of a 54-year-old immunocompetent man who developed worsening lower back pain of 2 weeks duration. A full spine magnetic resonance imaging (MRI) was performed with contrast. This showed extensive epidural abscess extending from C2 to S2, more extensive around L5-S2, with left paraspinal, left iliopsoas and right psoas abscess confirming the diagnosis of spinal epidural abscess of the spine. Blood cultures grew Streptococcus intermedius, an anaerobic commensal bacterium of the normal flora of the mouth and upper airways. The patient was treated conservatively with intravenous Ceftriaxone 2g and oral Rifampicin 600mg. He was discharged on those medication for 10 weeks. There was remarkable improvement in his symptoms as he retained his baseline strength in his lower extremity and has regained function to the extent that he is independent with his activities of daily living. A high index of clinical suspicion and a low threshold of appropriate imaging, magnetic resonance imaging (MRI) being the gold standard, are important for accurate diagnosis. Though our patient was treated Medically, Prompt medical and surgical treatment may avert complications, and although the patient presented made a complete recovery, patients may be left with neurological deficits.

A common complaint… a rare disease!

A 2-year-old previously well child presented to the emergency department with temperatures and lethargy. He was pale and looked unwell. He received a fluid bolus and was commenced on intravenous...

Indicated and non-indicated antibiotic administration during pregnancy and its effect on pregnancy outcomes: Role of inflammation

The objective of this study was to compare the release of endotoxin and pro-inflammatory cytokines as well as pregnancy outcomes after antibiotic exposure in healthy and bacterial infected pregnant rats. Thirty female Wistar pregnant rats were divided into five groups. Group A considered as control and received intraperitoneal saline 0.9% on 17th day of gestation or DG) and groups B and C treated with 20 mg/kg/day intravenous ceftriaxone and ceftazidime, respectively (DG: 18–20). Groups D and E received intraperitoneal E. coli and LPS on 17th DG respectively. Also, groups F and G received the same treatment as group D but they treated with the exact antibiotics mentioned for groups B and C (same dose and duration). Pregnancy outcomes as well as maternal sera levels of endotoxin, tumor necrosis factor α (TNF-α), interleukin 1β (IL-1β), and IL-6 were assessed using enzyme-linked immunosorbent assay. It was shown that group B had a higher IL-1β (P = 0.003) and TNF-α (P = 0.003) levels compared to the controls (CTC). Group C expressed a lower gestational duration (P = 0.007) as well as higher IL-6 (P = 0.025) and TNF-α (P < 0.001) levels CTC. Interestingly, both group B (P = 0.021) and C (P < 0.001) had a higher rate of endotoxin release CTC. Moreover, in group C, IL-6 (P < 0.0001 and r = −0.941) had a significant correlation with gestational duration. As the results showed, antibiotic administration in non-indication condition seems to be associated with significantly higher production of endotoxin and inflammatory cytokines which increase the risk of poor pregnancy outcomes.

Drug use evaluation (DUE) of ceftriaxone: A quality metric in a pediatric hospital.

Ceftriaxone is frequently used as empiric therapy because of its broad spectrum and dosing characteristics. The purpose of this study was to evaluate the appropriateness of ceftriaxone therapy among hospitalized children using drug use evaluation (DUE) methodology. Hospitalized patients who received one or fewer dose of intravenous ceftriaxone at Children's Hospital of Eastern Ontario between January 1, 2018, and June 30, 2018, were identified. Duration was defined as empiric if 72 or less and definitive if more than 72 hours. Two infectious disease physicians reviewed the charts and rated appropriateness using a previously developed scale. A total of 276 ceftriaxone courses in 248 patients (mean age 6.0 y) were reviewed. Of these, 153 (55.4%) were assessed as definitively or possibly indicated. The most common reason for inappropriate empiric use was an overly broad spectrum. Of the 120 courses given empirically for which there was no indication, the three most common reasons were lower respiratory infections (51; 42.5%), head and neck infections (18; 15.0%), and intra-abdominal infections (15; 12.5%). Of the 39 (14.1%) courses of ceftriaxone that were given for more than 72 hours, 14 (35.9%) met criteria for a definitive or possible indication. Ceftriaxone is still overused as empiric therapy. Although 85% of courses were discontinued after three doses, 14% were continued for longer than 72 hours, with approximately one-third ultimately meeting an indication. DUE using Canadian pediatric and local guidelines criteria is useful to identify clinical presentations for which narrower spectrum antimicrobials should be used.

MIGHTY MITIS

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Transcatheter Aortic Valve Replacement (TAVR) is the mainstay treatment of severe aortic stenosis especially in the elderly with multiple comorbidities and is emerging as an alternative to surgical aortic valve replacement (SAVR). (1) The rate of infective endocarditis (IE) following TAVR has been reported to be around 1.5%.(2) Herein, we describe a case where the patient developed prosthetic valve endocarditis (PVE) 2 months after undergoing TAVR. CASE PRESENTATION: A 73-year-old male presented to the emergency with cough, chills, and bilateral lower extremity swelling for a week. His medical history was significant for hypertension, hyperlipidemia, type 2 diabetes mellitus, bradycardia status post dual lead pacemaker (2013), and severe aortic stenosis status post TAVR (26mm SAPIEN 3 valve via right femoral artery- TAVR was done 2 months prior to this presentation). The patient underwent a dental procedure 3 weeks after the TAVR and did not receive any antibiotic prophylaxis prior to the dental procedure. Duke Criteria indicated ‘Possible infective endocarditis (IE)’. Transthoracic echocardiogram (TTE) did not show any vegetation. Blood cultures yielded Streptococcus mitis/ oralis. Transesophageal echocardiogram (TEE) showed 0.6 X 0.2cm vegetation on the left coronary cusp of the prosthetic aortic valve and mild paravalvular aortic insufficiency. The pacemaker was vegetation-free. He was started on intravenous (IV) ceftriaxone, responded well to it, and was discharged with a 6weeks course of IV ceftriaxone and he was referred to cardiothoracic surgery for further evaluation. DISCUSSION: IE is an uncommon complication after TAVR. PVE associated with TAVR is difficult to diagnose and has a dismal prognosis so TAVR- IE deserves prompt diagnosis and treatment. PVE presents with fever, new or changing heart murmur, new or worsening heart failure, or new or progressive cardiac conduction abnormalities. The most frequently encountered pathogens in early PVE (within two months of TAVR) are S. aureus and coagulase-negative staphylococci followed by gram-negative bacilli and fungi. The most frequently encountered pathogens in intermediate PVE (2 to 12 months after TAVR) and late PVE (more than 12 months after TAVR) are streptococci and S. aureus followed by coagulase-negative staphylococci and enterococci. The main sources of PVE are dental interventions and respiratory, skin, urological, and gastrointestinal infections.(2) Studies have shown that men are found to be affected by IE more often than women. (3) CONCLUSIONS: As per the American Heart Association (AHA) and the European Society for Cardiology (ESC) guidelines, PVE should be treated with a bactericidal agent for at least six weeks. Guidelines recommend early surgery in complicated cases including those with heart failure, perivalvular complications, and high risk of embolism. Emphasis should also be given on any pre-procedure prophylaxis. Reference #1: Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, PARTNER Trial Investigators. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187–98. Reference #2: Amat-Santos IJ, Ribeiro HB, Urena M, Allende R, Houde C, Bédard E, Perron J, Delarochellière R, Paradis JM, Dumont E, Doyle D, Mohammadi S, Côté M, San Roman JA, Rodés-Cabau J. Prosthetic valve endocarditis after transcatheter valve replacement: A systematic review. JACC Cardiovasc Interv. 2015;8:334–346. Reference #3: Olsen NT, Backer O De, Thyregod HGH, Vejlstrup N, Bundgaard H, Søndergaard L. Structural Heart Disease Prosthetic Valve Endocarditis After Transcatheter Aortic Valve Implantation. 2015;1–9. DISCLOSURES: No relevant relationships by Sanya Chandna, source=Web Response No relevant relationships by Kesavan Sankaramangalam, source=Web Response No relevant relationships by Monarch Shah, source=Web Response

NOCARDIOSIS PRESENTING LIKE A METASTATIC LUNG CANCER

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Nocardia is a gram-positive, weakly acid-fast, branching rod which is ubiquitous environmental saprophytes that cause localized or disseminated disease in both immunocompetent and immunocompromised patients. We present here a case of a 55-year-old male who was found to have right middle lobe lung abscess as well as right cerebellar abscess secondary to disseminated Nocardiosis from the pulmonary source. CASE PRESENTATION: A 55-year-old male with a past medical history of hypertension, hyperlipidemia, migraines, 30 pack-year smoking history, and emphysematous COPD presented to the hospital with 5 days of cough productive of clear sputum, headache and multiple episodes of emesis. He also reported 30 pounds weight loss over the last 1 year due to poor appetite. On presentation, he was hypoxic and tachypneic requiring 5 liters of oxygen by nasal cannula. Physical examination showed a cachectic male with decreased breath sounds bilaterally and crackles in the right lower lung field. The neurological exam showed nystagmus with right-sided gaze and square wave jerks as well as dysdiadochokinesia. Labs showed elevated WBC count at 17.6*10^3 with Neutrophilic pleocytosis. Chest CT showed right middle lobe lung mass, multiple bilateral pulmonary nodules as well as right lower lobe pneumonia. CT head showed right-sided cerebellar mass. Hence an emergent MRI was obtained to assess the mass which showed a large multiseptated cerebellar mass measuring 4.7 * 5.8 * 3.2 cm with mild vasogenic edema centered in the right cerebellar hemisphere crossing midline and producing severe stenosis of the fourth ventricle and resultant obstructive hydrocephalus. The patient was taken to the Operating room STAT and when the right cerebellum was entered a green-tinged fluid started draining which was sent for a culture that grew Nocardia cyriacigeorgica. The patient also had a bronchoscopic biopsy of the right-sided lung mass a day later which also grew the same organism. The patient was initially treated with Intravenous vancomycin, ceftriaxone and levofloxacin for broad-spectrum coverage for pneumonia and after the cultures grew Nocardia was switched to intravenous trimethoprim-sulfamethoxazole and meropenem after infectious disease consultation. However, he failed to respond to the therapy and was made comfort care and passed away. DISCUSSION: Disseminated disease with Nocardia involving brain and lung has been reported in both immunocompromised and immunocompetent patients. However, most of the cases reported in the literature are of elderly patients or immunocompromised patients. As the population of the United States is aging with many patients on immunomodulators it is imperative to raise awareness about disseminated nocardiosis CONCLUSIONS: Physicians must be aware that disseminated nocardiosis can mimic the presentation of metastatic lung carcinoma: early surgical intervention in brain abscess improves outcomes. Reference #1: Karan M, Vučković N, Vuleković P, Rotim A, Lasica N, Rasulić L. Acta Clin Croat. 2019 Sep;58(3):540-545. doi: 10.20471/acc.2019.58.03.20. Reference #2: Schlaberg R, Huard RC, Della-Latta P. Nocardia cyriacigeorgica, an emerging pathogen in the United States. J Clin Microbiol. 2008. Jan;46(1):265–73. 10.1128/JCM.00937-07 Reference #3: Lee GY, Daniel RT, Brophy BP, Reilly PL. Surgical treatment of nocardial brain abscesses. Neurosurgery. 2002. Sep;51(3):668–71, discussion 671–2. 10.1097/00006123-200209000-00010 DISCLOSURES: No relevant relationships by Fazal Raziq, source=Web Response No relevant relationships by Muhammad Usama, source=Web Response

&lt;p&gt;Group B Streptococcal Meningitis in a Healthy Young Woman: A Case Report&lt;/p&gt;

Group B streptococcus (GBS) is a rare cause of meningitis in adults that commonly affects patients with multiple underlying comorbidities. Although it is uncommon, it typically progresses very rapidly and has a high mortality rate as compared to other causes of bacterial meningitis. Here, we report a patient with GBS meningitis who had no underlying medical illness and presented with multiple episodes of seizure within hours of developing fever. Cerebrospinal fluid analysis results were consistent with bacterial meningitis, and blood cultures grew GBS. She was treated with intravenous ceftriaxone for 2 weeks and made a great recovery without any sequalae. In conclusion, although GBS meningitis is uncommon in adults, it is a serious medical disease and associated with a high mortality rate. To the best of our knowledge, this patient represents one of the few reported cases of GBS meningitis in a previously healthy young adult.

S1694 Colonic Ileus: A Rare Complication of Positive Pressure Ventilation

INTRODUCTION: Gastric insufflation may be seen in up to 30% of patients receiving non-invasive positive-pressure ventilation (PPV). However, it rarely causes significant observable effects given the integrity of the lower esophageal sphincter, which prevents large amounts of air from entering the gastric lumen. Here we report a rare complication of PPV. CASE DESCRIPTION/METHODS: A 68-year-old male with chronic obstructive pulmonary disorder and chronic kidney disease presented with one week of severe dyspnea, wheezing, and productive cough. The patient received intravenous ceftriaxone, azithromycin, and nebulized albuterol in the ED. Within hours, the patient oxygen saturation decreased to 60% and he became unarousable. The patient underwent tracheal intubation and was extubated the following day. The patient required BIPAP support for the next 4 days. On day 6 of hospitalization, the patient developed severe nausea and diffuse abdominal pain. Clinical examination was significant for firm abdominal distension, diffuse abdominal tenderness without rebound or guarding, and hyperresonance on percussion. Abdominal X-ray revealed a markedly dilated large bowel, concerning for large bowel obstruction versus ileus that was not present on admission (image 1). Subsequent CT imaging of the abdomen and pelvis revealed no free air, but diffuse distension of the proximal, transverse, and sigmoid colon, with the largest segment measuring 10.5 cm, consistent with large bowel ileus (image 2). After receiving multiple enemas and 2 liters of polyethylene glycol/electrolyte solution, the patient passed a significant amount of stool with complete resolution of his abdominal pain and distension. DISCUSSION: Gastrointestinal complications of PPV include stress ulcers, impaired gastric emptying, diarrhea, constipation, obstruction, and rarely, colonic perforation. Those with acute respiratory failure with superimposed COPD are at greater risk for developing ileus due to an increased risk of exaggerated aerophagia. PPV is associated with elevated catecholamines and increased sympathetic activity, which results in splanchnic hypoperfusion. This causes an oxygen supply and demand imbalance in the GI tract, resulting in mucosal damage and alterations in GI motility. In this case, acute colonic pseudo-obstruction developed after 6 days of PPV. It highlights the importance of careful assessment in patients at risk for exaggerated aerophagia due to the risk of colonic ileus and possible perforation.Figure 1.: Left: Chest X-ray on admission showing hyperinflated lungs without colonic dilation. Right: Abdominal X-ray hospital day 6 with colonic dilation.Figure 2.: CT abdomen and pelvis showing diffuse colonic dilation without perforation.

DEFERVESCENCE PERIOD OF AZITHROMYCIN VERSUS CEFTRIAXONE IN CHILDREN WITH ENTERIC FEVER

OBJECTIVES: To compare the defervescence period of azithromycin versus ceftriaxone in children with enteric fever. METHODS: This open-label, randomized-controlled trial was conducted at Pediatrics Department, Federal Government Polyclinic Hospital, Islamabad, Pakistan from June 30, 2015 to December 30, 2015. Sample Size calculated was 99 by using WHO Sample Size Calculator. Patients of either gender, aging 2-12 years, diagnosed as enteric fever were eligible for study. One hundred eligible patients selected through non-probability consecutive sampling technique were recruited in the study, after seeking an informed consent from the parents. These patients were randomized through lottery method in two groups of equal size (n=50 each). Group A, received oral azithromycin suspension/capsule (10mg/kg/day; maximum dose, 500mg/day) administered once daily for 7 days, while Group B received intravenous (I/V) ceftriaxone (75mg/kg/day; maximum dose, 2.5 g/day) administered twice daily for 10 days. The clinical response to the therapy of both drugs was calculated in terms of number of days taken for defervescence. Data was analyzed in SPSS version 22.0. RESULTS: Out of 100 patients, 64 (64%) were males and 36 (36%) were females and mean age of patients was 7.08±3.013 years. Patients on azithromycin had the mean time of defervescence 4.08±0.922 days and patients on ceftriaxone, the mean time of defervescence was 4.06±1.038 (p=0.919). CONCLUSION: There is no significant difference between oral azithromycin and intravenous ceftriaxone in term of defervescence period for the treatment of enteric fever in children. azithromycin could be a suitable alternative owing to its convenient dosing and monitored on outpatient basis.