Obvious Source Of Infection Research Articles

Assessing the clinical utility of abdominal computed tomography in sepsis patients with unknown origin: A retrospective cohort study.

Early identification of the sources of infection in emergency department (ED) patients of sepsis remains challenging. Computed tomography (CT) has the potential to identify sources of infection. This retrospective study aimed to investigate the role of CT in identifying sources of infection in patients with sepsis without obvious infection foci in the ED. A retrospective chart review was conducted on patients with fever and sepsis visiting the ED of Linkou Chang Gung Memorial Hospital between July 1, 2020 and June 30, 2021. Data on patient demographics, vital signs, clinical symptoms, underlying medical conditions, laboratory results, administered interventions, length of hospital stay, and mortality outcomes were collected and analyzed. Of 218 patients included in the study, 139 (63.8%) had positive CT findings. The most common sources of infection detected by CT included liver abscesses, acute pyelonephritis, and cholangitis. Laboratory results showed that patients with positive CT findings had higher white blood cell and absolute neutrophil counts and lower hemoglobin levels. Positive blood culture results were more common in patients with positive CT findings. Additionally, the length of hospital stay was longer in the group with positive CT findings. Multivariate logistic regression analysis revealed that hemoglobin levels and positive blood culture results independently predicted positive CT findings in patients with fever or sepsis without an obvious source of infection. In patients with sepsis with an undetermined infection focus, those presenting with leukocytosis, anemia, and elevated absolute neutrophil counts tended to have positive findings on abdominal CT scans. These patients had high rates of bacteremia and longer lengths of stay. Abdominal CT remains a valuable diagnostic tool for identifying infection sources in carefully selected patients with sepsis of undetermined infection origins.

SAT597 Pituitary Abscess Growing Serratia Marcescens With Associated Clivus Osteomyelitis

Abstract Disclosure: S. Brown: None. J. Milosavljevic: None. J. Chai: None. B.Y. Wong: None. Background: Pituitary abscesses are a rare etiology for pituitary lesions (0.2%-1.1%). Up to 60% of abscesses do not have an obvious source of infection. Pituitary abscesses can develop from the spread of local infection (usually the sphenoid sinus or cavernous sinus). Commonly isolated organisms of pituitary abscesses are gram positive cocci (Staphylococcus and Streptococcus) or gram negative bacilli (E. coli, Neisseria, and Corynebacterium). We present a case of a pituitary abscess growing Serratia marcescens with associated clivus osteomyelitis. Clinical Case: A 26-year-old woman with a history of recurrent left ear infections presented with right eye pain, sixth cranial nerve palsy and headaches. Brain MRI revealed 1.2 x 0.9 x 1.2 cm septated, cystic-appearing, rim-enhancing lesion originating from the sella, exerting mild pressure on the optic chiasm and infiltrating the right cavernous sinus. Contrast-enhanced CT scan revealed sclerotic and erosive changes concerning for clivus osteomyelitis and petrous apicitis. Hormonal evaluation demonstrated panhypopituitarism with undetectable cortisol (<1.0 µg/dL, n = 4-20 µg/dL), low ACTH (2.8 pg/mL, n = 7.2-63.3pg/mL), low-normal FT4 (0.6 ng/dL, n = 0.6-1.5ng/dL), low-normal TSH (0.32 µU/mL, n = 0.3-4.2µU/mL), undetectable estradiol (<25 pg/mL, n = 10-400pg/mL), low FSH (4.1 mIU/mL, n = <20 mIU/mL), low LH (0.5 mIU/mL, n = <10 mIU/mL), elevated prolactin (79 ng/mL, n<25ng/mL), and normal IGF-1 (192 ng/mL, n = 63-373ng/mL). Blood cultures, HIV testing, hepatitis serologies, Aspergillus galactomannan and cryptococcal antigen were negative. Replacement with hydrocortisone and levothyroxine was initiated, as well as empiric treatment with ceftriaxone, vancomycin, and metronidazole. Patient then underwent trans-sphenoidal evacuation of the sellar abscess. Specimen cultures grew Serratia marcescens. Post-operatively, she developed arginine vasopressin (AVP) deficiency and was started on desmopressin. Her symptoms and sixth nerve palsy resolved after surgery, and she was discharged with hormone replacements and a 6-week course of ceftriaxone. Conclusion: While other Enterobacteriaceae have previously been isolated from pituitary abscesses (including E. coli, Citrobacter, Salmonella, Proteus and Klebsiella), our case demonstrates, to the best of our knowledge, the first case of Serratia isolated from a pituitary abscess. Serratia is considered to be an opportunistic pathogen, although this patient had no identifiable risk factors for immunosuppression. Also, pituitary abscesses commonly spread from local infections. However, the source of infection in this case is likely the clivus osteomyelitis, which to the best of our knowledge, also has never been reported. In summary, this case differs from other reported cases due to the pituitary abscess growing Serratia with a potential source from the clivus osteomyelitis. Presentation: Saturday, June 17, 2023

THU360 Hyperglycemic DKA In Patient On Monotherapy With SGLT-2 Inhibitor

Abstract Disclosure: S. Ahmed: None. L. Medina Mora: None. A. Sanchez Ruiz: None. L. Poretsky: None. Background: SGLT2 inhibitors have a rare but increasingly reported risk of euglycemic diabetic ketoacidosis. Hyperglycemic diabetic ketoacidosis is not an expected risk of SGLT-2 inhibitors. Clinical Case: 52-year-old male with history of type 2 Diabetes presented with progressive weakness, shortness of breath, nausea and vomiting worsening over 48 hours. He reported increased polydipsia and polyuria. Patient was found to have a blood glucose of 685 mg/dL associated with an anion gap of 28 mm/L and bicarbonate level of 6 mm/L. Beta hydroxybutyrate level was >8.0 mmoL/L. He was diagnosed with hyperglycemic diabetic ketoacidosis, given intravenous isotonic fluid and started on an insulin drip. The anion gap closed and he was successfully transitioned off the insulin drip to a basal bolus regimen of insulin. The patient improved quickly without any complication. The patient was never on insulin therapy prior to admission. No obvious source of infection was discovered to precipitate the event. The patient had a 7-year history of diabetes and was only managed on oral medications at home. He was previously on Janumet 50-1000mg twice a day and changed to only dapagliflozin 10mg 9 months prior to the current episode. He never experienced ketoacidosis or hyperosmolar hyperglycemic state. Hemoglobin A1c was found to be 8.0%. He reported that his A1c levels were always less than 8%. Autoimmune workup for type 1 Diabetes was done. C-peptide level was found to be 1.5ng/mL. Patient appeared to have an adequate insulin level despite the recent event of diabetic ketoacidosis. Patient was discharged on 10 units of Glargine® at bedtime and 3 units of Lispro® before meals. He was given glucometer teaching with an appointment for endocrine follow up. During follow up Glutamic Acid decarboxylase, Islet cell, Insulin and Zinc 8 transporter antibodies have come back negative. Patient is being planned for transition to oral antihyperglycemic agents which will not include an SGLT2 inhibitor. A MODY panel is pending results for further evaluation. Conclusion: Monotherapy of SGLT-2 inhibitors appears to not only have a risk of euglycemic diabetic ketoacidosis but also a risk of hyperglycemic diabetic ketoacidosis in type 2 diabetics. In this case we presented a case of hyperglycemic diabetic ketoacidosis in a type 2 diabetic on therapy with dapagliflozin. Presentation: Thursday, June 15, 2023

Frequency of Urinary Tract Infection in Febrile Children without Any Focus on Infection

Background: In newborns and young children, a urinary tract infection is a frequent hidden cause of fever. Children younger than a year old who appear with fever and symptoms of UTI are usually given treatment for something else. Objectives: The objective of this study was to assess the prevalence of UTI in children presenting to a tertiary care hospital between the ages of 1 month and 36 months with nonspecific fever. Duration and study settings: The Children's Hospital Pakistan Institute of Medical Science, SZABMU, Islamabad, was the site of this trial, which ran from Jan 2018 to June 2018. Study design: Descriptive cross sectional Methodology: After a complete medical history and physical examination, a urine sample was taken for testing and culture using a soft tube in younger children and a clean catch approach in older children or those who are cooperative. Urisys 2400 was used to analyse the urine samples. Larger children's urine samples were grown on CLED agar plates (cysteine lactose, electrolyte deficient). Clinitek Siemens, a haematology analyser, was used to determine the number of white blood cells in the blood. The Pakistan Institute of Medical Sciences in Islamabad is home to a state-of-the-art laboratory where tests including leucocyte count, urine DR, and culture were conducted. A pre-designed proforma was used to record the patient's demographic information, medical history, diagnosis, and laboratory results. Results: In this study, 6.47 percent (n=18) of 278 children aged 1 to 36 who presented to a tertiary care hospital with a fever and no other obvious signs of infection were found to have a urinary tract infection. Conclusion: Children arriving to a tertiary care hospital with a fever and no other signs of infection are not likely to have a urinary tract infection. Keywords: UTI in children with diffuse fever and no obvious source of infection.

WHAT IS GOOD FOR THE GOOSE IS GOOD FOR THE GARDNER: RARE CASE OF SEVERE SEPSIS AND ORGAN FAILURE DUE TO GARDNERELLA VAGINALIS INFECTION IN A HEALTHY MALE PATIENT

WHAT IS GOOD FOR THE GOOSE IS GOOD FOR THE GARDNER: RARE CASE OF SEVERE SEPSIS AND ORGAN FAILURE DUE TO GARDNERELLA VAGINALIS INFECTION IN A HEALTHY MALE PATIENT

P29 An unusual case of reactive arthritis

Introduction/BackgroundThis 28-year-old gentleman with a background of cerebral palsy was admitted to hospital feeling generally unwell with pyrexia as well as a red, hot and swollen right knee. He had communication and mobilty issues at baseline but was very unsettled and less mobile than normal.CRP was over 100 and elevated temperatures were recorded. Ultrasound confirmed a small right knee effusion which was subsequently aspirated with no growth on culture. Crystal analysis on this sample was also negative.Intravenous antibiotics were commenced and the patient was managed as a septic joint with no other obvious source of infection.Description/MethodAntibiotics led to improvement in temperatures and inflammatory markers. A trial off antibiotics led to return of fever, elevated inflammatory markers and knee symptoms. In addition to this a red, hot and swollen left elbow evolved as well as discomfort in neck and left shoulder. Blood cultures remained negative. Repeat knee aspirate remained negative on culture.Antibiotics were restarted.An additional problem during admission was constipation which had been a chronic issue that had been worsened.Abdominal xray showed a 10cm faecolith in the rectum. The case was discussed with the gastro intestinal and surgical teams and conservative management was recommended with escalation of laxatives with only minimal success.MRI spine showed no discitis. MRI knee showed moderate knee effusion but no osteomyelitis. CRP fluctuated with joint flares over the coming weeks with antibiotics adjusted accordingly.CT chest abdomen and pelvis to look for an alternative infective source showed massive distention of sigmoid colon with partially calcified faeculant material, with mass effect on the urinary bladder. An infective source was not definitively identified.The case was discussed with the surgical team again with further usage of enemas to little effect. Ultimately the patient had a manual evacuation performed under anaesthetic in theatre with large volumes of faeces removed. Bowels moved well with ongoing laxatives and his joints remained settled from this point on.Discussion/ResultsThis patient had been in hospital for 10 weeks in 2019 with recurring bouts of inflammation in knee and elbow alongside pyrexias and elevated inflammatory markers. Within 48 hours of manual evacuation of a large, chronic faecolith his joints were completely settled and patient was discharged to have no further joint issues since.The joint issues were initially felt to be an infective aetiology and therefore managed with antibiotics but with the discovery of the large faecolith and subsequent removal of this and settling of joints, this appears to have been a inflammatory arthritis presumably reactive to the chronic constipation.Key learning points/ConclusionThis was a very interesting case in a young man with physical and mental disabilities with joint pain and swelling and a prolonged hospital admission. Chronic constipation appears to have been the trigger for these inflammatory joints and highlights the point to consider less common causes of inflammatory, reactive arthritis.

Man With Fever and Hypotension

An 82-year–old man with a past medical history of stroke, diabetes mellitus, and hypertension presented to the emergency department with a 1-day history of fever and hypotension. His vital signs at presentation were blood pressure 79/42 mmHg, pulse 129 beats/min, and temperature 39.2 °C (102.6 °F). The patient’s history and physical examination were unremarkable, with no obvious source of infection. Blood test results revealed an elevated level of WBCs of 18.4 × 109/L. During fluid status assessment, a bedside ultrasound investigation revealed a crescent-shaped structure at the junction of the inferior vena cava and right atrium (Figure 1).

Non-Fasting Hypoglycemia Secondary to Opioid Induced Adrenal Insufficiency: A Case Report

Abstract Background: A patient on chronic methadone therapy presented following a suicide attempt, was noted to have recurrent episodes of non-fasting symptomatic hypoglycemia and was diagnosed with opioid induced adrenal insufficiency (OIAI). Opioid induced endocrinopathies are underappreciated, particularly in the midst of a growing opioid epidemic in the United States. We believe this is the first reported clinical case of OIAI associated with non-fasting hypoglycemia. Clinical Case: A 33-year-old female with history of depression and heroine abuse on methadone therapy presented after a suicide attempt by methadone overdose. Home medications included 170mg of methadone daily for the past 5 years. She was afebrile, heart rate of 68, blood pressure 102/72, respiratory rate of 10, oxygen saturation 92%. On exam she was lethargic with altered mental status and had pinpoint pupils. Labs showed a normal complete blood count and metabolic panel. Urine toxicology was positive for methadone. Clinical picture improved temporarily after Narcan administration however 1 hour later she was confused again, with a fingerstick glucose of 50mg/dL and she was admitted to ICU for monitoring. In the ICU she continued to be lethargic with dizziness, nausea and headaches. She continued to have approximately 4 spontaneous episodes of hypoglycemia per day, despite having a good appetite and increased parenteral glucose administration. Blood pressure continued to be marginal, ranging from 85–100/50–60. There was no obvious source of infection. Urine sulfonylurea screen was negative. Investigations showed a morning cortisol of 2.23 ug/dL. A 250 µg ACTH stimulation test showed an inadequate response. The am basal plasma cortisol was 2.25 ug/dL with 15.28 ug/dL and 15.13 ug/dL at 30 and 60 minutes respectively (6.20–19.40ug/dL). She was diagnosed with hypoglycemia secondary to OIAI. Given the patient’s critical condition she was initially started on stress dose of hydrocortisone 80mg every 8 hours. Attempts to down titrate the methadone dose were unsuccessful. Patient’s symptoms improved and hypoglycemia subsided. She was discharged home on hydrocortisone 10mg qam & 5 mg qpm and she was continued on Methadone 170mg daily. Conclusion: OIAI is an under-recognized clinical entity with potentially serious adverse outcomes. Currently, 3% to 4% of US adults receive long-term opioid treatment. OIAI is present in 9—29% of individuals on chronic opioids. Opioids act through suppression of the HPA axis, primarily at the level of the hypothalamus, mediated through either delta or kappa receptors leading to a decrease in ACTH and cortisol secretion. Management should include decreasing and ideally discontinue opioids, along with glucocorticoid replacement until documented recovery of the HPA axis. Reference: Reference: (1)Donegan, Diane et al. Opioid-Induced Adrenal Insufficiency. Mayo Clin. Proc. 2018 93(7), 937–944.

RARE CASE OF OVERLAPPING PRIMARY EFFUSION LYMPHOMA AND KAPOSI SARCOMA INFLAMMATORY CYTOKINE SYNDROME IN IMMUNOSUPRESSED PATIENT

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Kaposi’s sarcoma-associated herpes virus (KSHV) is a potent oncogenic and immunomodulatory virus. We present a patient with high KSHV viral load with primary effusion lymphoma (PEL) and the rarely reported Kaposi’s sarcoma inflammatory cytokine syndrome (KSICS). CASE PRESENTATION: 31-year-old male with AIDS (CD4 of 45 cell/µL, viral load 170,000) and Kaposi Sarcoma treated with liposomal doxorubicin, admitted for shortness of breath (SOB), lower extremity (LE) and scrotal edema. Physical examination: tachycardia, bibasilar crackles, 3+ pitting edema of LE extending to the sacrum, and violaceous, erythematous KS lesions on the torso. Initial studies notable for anemia (Hgb 9.0 g/dl), otherwise unremarkable including brain natriuretic peptide and microbiology studies. A chest x-ray demonstrated bilateral pleural effusions with loculation on the left, which was later confirmed on a chest computed tomography scan, that also revealed enlarged mediastinal lymph nodes. Echocardiography showed preserved ejection fraction. A doppler ultrasound of LE was negative for deep vein thrombosis. During hospital course, patient became progressively anemic, hemodynamically unstable and profoundly SOB, ultimately requiring transfer to the intensive care unit where he was intubated and started on vasopressors. A thoracentesis with cytology positive for large pleomorphic lymphocytes, CD45+/HHV8+/EBER+ by immunohistochemistry. Flow cytometry showed monotypic B-cell population positive for HLA-DR, CD38, CD45 (dim), and kappa light chain (dim) restricted, consistent with a diagnosis of PEL. Serum studies demonstrated markedly elevated levels of IL6 and IL10 and the clinical presentation suggested a rare condition associated with KSHV, KSICS. The patient unfortunately died despite resuscitative efforts. DISCUSSION: PEL is the least common of all HIV related lymphomas and presents as lymphomatous growth in a liquid phase in a body cavity without extracavitary lesions. The pathogenic mechanism of KSHV is uncertain but almost all cases are associated with this virus. Malignant cells are monoclonal B cells that express CD38 and contain KSHV viral inclusions and the majority demonstrate EBV coinfection . Another disease diagnosed in patient is KSICS, a rarely reported systemic inflammatory syndrome associated with high KSHV viral load and elevated IL6 and IL10, secreted by infected cells. Presentation is similar to sepsis but without obvious source of infection. CONCLUSIONS: This case illustrates varying and overlapping presentations of KSHV infection in immunocompromised patient. Therapy does not exist and KS could not be treated due to the poor condition of patients. Patients have a high mortality rate and often misdiagnosed. Our patient received antibiotics for the presumptive sepsis before a diagnosis was made. It will be important to recognize this syndrome early to support attempts to develop effective therapies. Reference #1: Narkhede M, Arora S, Ujjani C. Primary effusion lymphoma: current perspectives. Onco Targets Ther. 2018;11:3747–3754. Published 2018 Jun 28. doi:10.2147/OTT.S167392 Reference #2: Polizzotto MN, Uldrick TS, Hu D, Yarchoan R. Clinical Manifestations of Kaposi Sarcoma Herpesvirus Lytic Activation: Multicentric Castleman Disease (KSHV-MCD) and the KSHV Inflammatory Cytokine Syndrome [published correction appears in Front Microbiol. 2017 Aug 21;8:1572]. Front Microbiol. 2012;3:73. Published 2012 Mar 2. doi:10.3389/fmicb.2012.00073 DISCLOSURES: No relevant relationships by Arsenije Kojadinovic, source=Web Response No relevant relationships by Prabhjot Mundi, source=Web Response No relevant relationships by Pahnwat Taweesedt, source=Web Response

Purulent pericarditis and mediastinal abscess in a young infant

A thriving, previously healthy 3-month-old girl presented with a 4-day history of fever, irritability and poor feeding. On admission, she was tachycardic, had cool peripheries with normal central perfusion, pulse...

Hepatitis A—2017 an unusual year in Scotland

BackgroundThe number of cases of acute hepatitis A reported in Scotland each year is small, and the majority of cases have been associated with travel to endemic regions. However, in early 2017, in the midst of ongoing outbreaks of hepatitis A among MSM in Europe, there was a sharp rise in the number of cases reported to Health Protection Scotland. ObjectivesThe initial aim of this study was to investigate the reason for the observed increase in cases of hepatitis A at the start of 2017. As cases continued for the remainder of the year, these cases were typed to determine whether these cases were linked to each other, or other outbreaks. Study designThe study population consisted of 42 hepatitis A infected patients with no obvious source of infection. The patient samples were collected between January and December 2017. The VP1/2 A region was amplified and sequenced. ResultsThe majority of samples typed as genotype 1 A (n = 17) or genotype 1B (n = 15). Within genotype 1 A, fifteen samples had strains (VRD_521_2016 or RIVM_HAV16_090) associated with ongoing outbreaks of hepatitis A in MSM in Europe. Within genotype 1B, there were four clusters of infections, with identical cases in geographically distinct regions with no identified epidemiological link. ConclusionsMolecular typing proved useful, as it allowed public health to identify clusters, establish links with other outbreaks and compare Scottish strains with those reported elsewhere.

MULTIPLE CEREBRAL ABSCESSES IN DECOMPENSATED CIRRHOSIS OF LIVER AS A MIMICKER OF HEPATIC ENCEPHALOPATHY: A CASE REPORT

Cirrhosis of the liver is a state of immune dysregulation. It can give way to many infections. Brain abscess, though uncommonly reported in cirrhotic patients, deserves special attention as it presents a diagnostic and therapeutic challenge for physicians. We present here, the case of a 65-year-old diabetic and hypertensive female patient, with cirrhosis of the liver, who presented to us with fever and altered sensorium. She had mild neutrophilic leukocytosis and her serum ammonia level was slightly elevated. She was managed conservatively for hepatic encephalopathy precipitated by infection. No obvious source of infection was found on routine investigation and culture. Broad-spectrum intravenous antibiotic coverage was provided at the earliest, but the patient succumbed to multiorgan failure.

Risk factors and microbial profile of central venous catheter related blood stream infection in medical cardiac care units, National Heart Institute, Egypt.

IntroductionCatheter related blood stream infection (CRBSI) is the main complication of central venous catheter (CVC) use. The aim of the study is to improve the safety of patients with central venous catheter in National Heart Institute (NHI) medical cardiac care units.MethodsA Prospective cohort study was conducted on one hundred and eleven cardiac patients in (NHI) cardiac care units from August 2017 to February 2018. All patients subjected to central venous catheter (CVC) in cardiac care units, NHI, were included except: 1. Patients with obvious source of infection, 2. Immunocompromised patients, 3. patients having infective endocarditis, 4. patients whose catheter was put outside NHI.ResultsNoncompliance of health care providers to care bundle elements of CVC of Centers for Disease Control and Prevention (CDC) represents a risk factor for CRBSI occurrence. Coagulase negative staphylococci was the most common isolated organism.ConclusionHealth care providers should adhere care bundle elements recommended by CDC during insertion and handling of CVC. This will in turn decrease CRBSI.

Trends in the Incidence of Staphylococcus aureus Bacteremia at a Teaching Hospital in Nassau, Bahamas 2012 to 2015

Background Staphylococcus aureus bacteremia (SAB) is a leading cause of infection-related morbidity and mortality within healthcare systems. A rising incidence of SAB has been seen in institutions with advances in medical interventions. Infectious Diseases consultation has proven to result in improved outcomes in affected patients. There are sparse data regarding incidence and outcomes of SAB in the Caribbean healthcare system.MethodsA retrospective sample of adult patients, admitted to a teaching hospital in Nassau, Bahamas with SAB between 1 January, 2012 and 31 December, 2015, was identified using patient medical records and microbiology database. Only patients ≥18 years with a first episode of SAB were included. Corresponding dockets were reviewed and data analyzed using Microsoft Excel and the 2015 version of the Statistical Package for the Social Sciences.ResultsOf all patients ≥18 years of age with positive blood cultures, a first episode of SAB was seen in 10.3% (201) of cases. Males represented 62.69% of cases with the 40–59 age group being most affected (42.52%). Most patients had Diabetes mellitus (37.31%) and End stage renal disease on dialysis (31.34%). No obvious source of infection was identified in 43.78%. Regarding source of acquisition, 12.44% were Nosocomial, 67.66% Healthcare-associated and 19.9% Community acquired.For the study period, there was a significant 4.4% increase in occurrence (range of 8.66% to 11.54%) of SAB. MSSA represented 73.68% of cases with incidence ranging from 55.67/1,000 (2013) to 95.89/1,000 (2014) while MRSA bacteremia had an incidence ranging from 17.96/1,000 (2012) to 35.37/1,000 (2015).30-day SAB mortality for the study period was 29.35% (range of 22.22% to 32.20%). The odds of death within 30 days from MRSA compared with MSSA was 1.90 (P = 0.056). The 30 -day risk of death from community acquisition was 3.25 (P = 0.001) compared with healthcare and 2.57 (P = 0.08) compared with nosocomial.ConclusionSAB remains an important bacterial infection with alarmingly high 30 day mortality rates being demonstrated in this study. Strategies such as Infectious Disease consultation, improved antimicrobial stewardship and timely interventions are warranted to improve outcomes in these patients.Disclosures All authors: No reported disclosures.

Chills During Hemodialysis: Prediction and Prevalence of Bacterial Infections – A Retrospective Cohort Study

IntroductionChills are a complication of patients undergoing hemodialysis. The rate of infection among hemodialysis patients presenting with chills is not well established, and empirical broad-spectrum antibiotics are usually the rule. MethodsWe performed a retrospective study aiming to assess the rates of infection and bacteremia in hemodialysis patients presenting with chills. We evaluated risk factors for infection and bacteremia and tested a prediction model for infection. ResultsOverall, 269 hemodialysis patients with a first episode of chills were included. Ninety patients (33.5%) had bacteremia and 162 (60.2%) had an infection. Risk factors for bacteremia in multivariate analysis included fever (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1-2.3; P = .009) and vascular catheter as dialysis access (OR 6.2; 95% CI, 3.2-12.0, P <.001). Leukocytosis was an additional risk factor in multivariate analysis for any type of infection (OR 1.265; 95% CI, 1.113-1.438; P <.001). Using a prediction model to evaluate patients without obvious source of infection, we found that patients with fistula or graft as their access, without fever, abnormal leukocytes, or hypoalbuminemia, had a low rate (1/17, 6%) of bacteremia. ConclusionsHemodialysis patients presenting with chills during dialysis, with or without fever, have high rates (∼60%) of infection. Patients with no obvious source of infection, with fistula or graft as access, presenting without fever, leukocytosis, or hypoalbuminemia have low risk for bacteremia and may be investigated without prompt antibiotic treatment. All other patients should receive antibiotic coverage immediately following a chills episode.

Bacteremia due to Streptococcus tigurinus: A case report and literature review

Gene sequence analysis methods, including 16S rRNA identification, allows accurate identification of Streptococcus species, which include phenotypically closely related species that are difficult to differentiate using conventional chemical methods. We report a case of bacteremia due to Streptococcus tigurinus, identified by 16S rRNA, in a 72-year-old woman with gastrointestinal cancer and ascites. She was hospitalized to undergo elective tumor-related surgery. Five days prior to undergoing surgery, she developed a fever with no obvious source of infection. Blood cultures identified gram-positive cocci. The patient's bacteremia was initially thought to be caused by an Enterococcus species, given her underlying gastrointestinal disease. However, alpha-hemolytic, mucoid, circular colonies were observed on sheep blood agar the following day. Although matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and biochemical testing suggested Streptococcus pneumoniae, we conducted further investigation to identify the bacterium, as the patient had no symptoms of infections usually related with S.pneumoniae such as pneumonia, meningitis, or sinusitis, and the bacteremia occurred 30 days after hospitalization. Finally, the gram-positive cocci were identified as S.tigurinus, assigned to the Streptococcus mitis group in 2012. Although the origin of infection was unclear, it was suspected that peritonitis or bacterial translocation from the gastrointestinal tract caused the bacteremia. This novel species was recently reported as being extremely pathogenic and different from other Streptococcus species. It has been reported to occur in cases of infectious endocarditis and bacteremia. In this article, we reviewed previous reports of S.tigurinus infection and summarized the clinical and pathogenetic features.

Streptococcus anginosus Septicemia, Sole Presentation of Silent Colorectal Tumor: A Case Report

Introduction:Streptococcus anginosus (S. anginosus is a subgroup of viridans streptococci). Considered to be of low virulence, their ability to cause systemic abscesses sets them apart from the other streptococci groups. The association of Streptococcus bovis endocarditis with colonic adenocarcinoma is well known; however, other species of viridans streptococci, especially S. anginosus, can be associated with an underlying colonic malignancy. This is relevant for patients without GI screening, as it can be an early sign of colonic neoplasm. Case Report: We present a case of a 62-year-old male with PMH of HTN, type 2 DM, HLP with history of rectal polyps s/p resection, who presented with 1-2-day c/o fever, chills, fatigue, and watery diarrhea. On presentation, he was septic and was resuscitated with fluids. Blood cultures were drawn and empiric antibiotics were started. Both cultures grew S. anginosus. His physical exam was benign and there was no obvious source of infection. A TEE was done to rule out endocarditis, and was unremarkable. CT scan of the abdomen and pelvis with contrast revealed lobulated hypodense lesion in the liver and irregular thickening in the rectum s/o neoplasm. IR-guided biopsy of the liver lesion was consistent with a pyogenic abscess, and colonoscopic biopsy of the rectal lesion showed tubulovillous adenoma without any dysplasia. The patient was treated for 6 weeks with IV antibiotics, which lead to resolution of the liver abscess. The rectal adenoma showed extension into muscularis propria on EUS, and therefore, was un-resectable. Eventual biopsies showed dysplastic conversion. The patient will undergo elective LAR with loop ileostomy. Discussion:S. anginosus forms part of the normal flora of the GI tract of both adults and children. As mentioned above, they are known for their tendency to form abscesses. On the other hand, Streptococcus bovis endocarditis is strongly associated with colonic adenocarcinoma. Our case stresses the importance of considering colonic malignancy in cases with viridans streptococci bacteremia, as it might be an early manifestation of the same. Therefore, in patients like ours with S. anginosus bacteremia, if no clinically apparent signs of abscess are visible, we recommend doing radiographic investigation with CT scan and early GI screening to look for drainable collections and colonic neoplasm. Treatment involves using third generation cephalosporins or beta lactam/beta lactamase combination along with abscess drainage. Conclusion: Although further evidence is needed to warrant colonoscopic work-up of S. anginosus bacteremia, our case stresses the importance of early radiologic investigation of the abdomen with special emphasis on the colon, as it may be an early sign of colonic neoplasm.

PWE-135 Hepatitis E: An Emerging Infection in North East of Scotland?

IntroductionHepatitis E virus (HEV) is enterically transmitted and is endemic in some areas of the world. In the UK it was generally thought to be associated with travel but infection...

Urinary tract infection among neonates in Benin City, Nigeria

Urinary tract infection (UTI) is the most common serious bacterial infection found in febrile infants and young children who present without an obvious source of infection. This study aimed to determine the prevalence of UTIs among neonates in Benin City, Nigeria. Suprapubic urine aspirate or catheter urine specimens were obtained from 266 (85 male and 181 female) neonates with signs and symptoms of UTI. Significant microbial isolates were identified in the urine specimens, and an antimicrobial susceptibility test was performed on bacterial isolates using standard techniques. Male sex was a significant risk factor for acquiring UTI in the neonates (odds ratio = 4.336, 95% confidence interval = 1.546–12.112, p = 0.0064). Klebsiella species were the organisms most prevalent in causing UTIs (28.57%) within all age groups of neonates. Candida albicans was recovered only from neonates within the first week of life. Although bacterial isolates were more susceptible to nitrofurantoin, the susceptibility profiles of bacterial isolates were generally poor. An overall UTI prevalence rate of 6.39% was observed among neonates. Male infants had an approximately 2–12-fold increased risk of acquiring a UTI, and Klebsiella species were the isolates most predominant in causing neonatal UTI. Rational use of antibiotics is advocated to stem the tide of antibacterial resistance.

Mycotic Pseudoaneurysm of the Superficial Femoral Artery in a Patient with Cushing Disease: Case Report and Literature Review

Mycotic pseudoaneurysms of the peripheral arteries are rare and can occur as an extension of localized infection or from systemic sepsis. In some cases, no obvious source of infection may be identified. Both endovascular and open surgical management options are available for this important condition. We report a mycotic pseudoaneurysm of the superficial femoral artery in a patient associated with systemic immunosuppression secondary to Cushing disease that was successfully managed with open surgical repair and autologous bypass grafting. This unusual case highlights the potential for serious adverse cardiovascular sequelae of Cushing disease and the need for awareness of such complications in this patient group.