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Only about 40 cases of septic arthritis of the facet joints have been reported to date. We report 6 new cases including 2 at the cervical spine, which is rarely involved. Mean age was 61.5 years; there were 5 men and 1 woman. Spinal pain and stiffness, fever, and asthenia were the presenting manifestations. Laboratory tests consistently showed inflammation. Among classical risk factors for infection, only noninsulin-dependent diabetes was noted, in a single patient. Mean time to the diagnosis was 42 days. Discitis, a far more common condition, was considered initially, and early radiographs were of limited diagnostic assistance. Radionuclide bone scans identified the site of the infection and served to look for other foci. Magnetic resonance imaging was effective in confirming the diagnosis at an early stage and in looking for local spread (muscles, epidural space, and disk). L3-L4 was involved in 3 patients, C4-C5 in 2, and L4-L5 in 1. Direct inoculation during mesotherapy sessions was the cause in 1 patient. Cultures of blood and needle biopsy samples were positive in all 6 cases; Staphylococcus aureus was the causative agent in 3 patients. The risk of local and systemic complications governs the prognosis of facet joint infection. Of our 6 patients, 4 experienced complications: there was 1 case each of discitis, epidural infection, endocarditis, and septic arthritis of the acromioclavicular joint. Fatal multiple organ dysfunction occurred in 1 patient. In the other 5 patients, antimicrobial therapy and protection from weight-bearing for 3 months ensured a favorable outcome.
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PMID:A particular form of septic arthritis: septic arthritis of facet joint. 1809 63

Acute postinfectious glomerulonephritis (APIGN) is uncommon in adults, and its incidence is progressively declining in developed countries. To our knowledge there are no modern North American series addressing epidemiology and outcome. Here we report the clinical and pathologic findings in 86 cases of adult APIGN diagnosed by renal biopsy in a large New York referral center between 1995 and 2005. The male:female ratio was 2:1, and mean age was 56 years, with 33.7% aged older than 64 years. Of the patients, 38.4% had an immunocompromised background, including diabetes (29.1%), malignancy (4.7%), alcoholism (2.3%), acquired immunodeficiency syndrome (AIDS) (2.3%), and intravenous drug use (1.2%). The most common sites of infection were upper respiratory tract (23.3%), skin (17.4%), lung (17.4%), and heart/endocarditis (11.6%). The 2 most frequently identified infectious agents were streptococcus (27.9%) and staphylococcus (24.4%). Hypocomplementemia was present in 73.9% of patients. The most common histologic patterns were diffuse (72.1%), focal (12.8%), and mesangial (8.1%) proliferative glomerulonephritis. Outcome analysis was performed on the 52 patients with a follow-up of >/=3 months (mean, 25 mo). Among the 41 patients without underlying diabetic glomerulosclerosis, 23 (56.1%) achieved complete remission, 11 (26.8%) had persistent renal dysfunction, and 7 (17.1%) progressed to end-stage renal disease (ESRD). Of the 11 patients with underlying diabetic glomerulosclerosis, 2 (18.2%) had persistent renal dysfunction, and the remaining 9 (81.8%) progressed to ESRD (p < 0.001). In patients without underlying diabetic glomerulosclerosis, correlates of complete remission were younger age, female sex, lower serum creatinine at biopsy, and absence of immunocompromised state. By multivariate analysis, age and serum creatinine at biopsy inversely correlated with complete remission, and serum creatinine at biopsy was the only correlate with ESRD. Outcome did not correlate with any pathologic feature (including crescents) or steroid treatment. Diabetes and aging have emerged as major risk factors for adult APIGN. Full recovery of renal function can be expected in just over half of patients, and prognosis is dismal in those with underlying diabetic glomerulosclerosis.
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PMID:Acute postinfectious glomerulonephritis in the modern era: experience with 86 adults and review of the literature. 1820 67

A case of intravenous precipitation of erythromycin is reported along with the patient history, pathologic findings, and a description of the analytical methods and results. The patient was a 75-year-old woman with a history of myocardial infarction, deep venous thrombosis, and diabetes mellitus who underwent aortic valve replacement. She developed endocarditis and recurrent episodes of urosepsis, with multiple organ failure including severe gastric retention, for which she was treated with erythromycin intravenously. She died because of refractory septic shock. Autopsy revealed aortic valve endocarditis, thrombi in the right femoral vein, arterial (nonfungal) thromboemboli in the celiac trunk, and coarse material in the right femoral vein where the tip of the central venous catheter had been located. Microscopical examination of the coarse material showed that it was birefringent crystalline material. Part of the postmortem material was analyzed in the laboratory of the department of clinical pharmacy and revealed the presence of erythromycin. Erythromycin was detected using Fourier transform infrared spectroscopy. An additional specific color test and thin-layer chromatography confirmed this finding. On the basis of the postmortem findings, patient history, and analytical-toxicologic results, we conclude that erythromycin precipitation can occur in vivo after intravenous administration in patients with impaired blood flow.
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PMID:Erythromycin precipitation in vena femoralis: investigation of crystals found in postmortem material of an intensive care unit patient. 1822 76

The human eye, as an organ, can offer critical clues to the presence of systemic disease. This article discusses the various ophthalmologic manifestations of systemic disease that can be evident on examination by an emergency department provider, as well as some findings that can be discerned with specialty consultation. The following topics are reviewed with respect to potential ocular signs and complications: syphilis, herpes zoster, Lyme disease, acquired immunodeficiency syndrome, Reiter's syndrome, Kawasaki's disease, temporal arteritis, endocarditis, hypertension, and diabetes mellitus. Indications for emergent ophthalmologic consultation are also emphasized.
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PMID:Ophthalmologic complications of systemic disease. 1824 64

In 2007, several international studies brought useful information for the daily work of internists in hospital settings. This summary is of course subjective but reflects the interests and questions of the chief residents of the Department of internal medicine who wrote this article like an original trip in medical literature. This trip will allow you to review some aspects of important fields such as heart failure, diabetes, endocarditis, COPD, and quality of care. Besides the growing diversity of the fields covered by internal medicine, these various topics underline also the uncertainty internists have to face in a practice directed towards evidence.
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PMID:[Highlights 2007 in hospital-based internal medicine: the point of view from the chief residents]. 1838 35

In the last 30 years, major improvements have been made in understanding the pathogenesis, diagnosis and treatment of infective endocarditis. Nevertheless, mortality still remains high, close to 30-40% at 1 year, and its reduction remains the main challenge. Moreover, important epidemiological changes have been recorded. Social changes in Western countries have led to an increase in the mean length of life, and thus in degenerative valvular diseases, whereas rheumatic heart disease has almost disappeared. Increasing medicalization has led to a rise in complications and diseases related to longer hospital stay, surgical therapies and other invasive interventions. At the same time, there is an increase in immunosuppressive therapies, diseases such as cancer, diabetes mellitus and renal insufficiency that may enhance the disease. Further knowledge is needed for specific subgroups to improve both treatment and prognosis. Nevertheless, randomized trials are lacking to guide the management of the disease, and the role and indications of antibiotic prophylaxis are still the subject of debate. International multicenter studies are providing new important findings based on the experience of tertiary centers; these results may reflect referral biases. The proposal of an Italian national registry on infective endocarditis (RIEI) will overcome these limitations and provide a wide picture of the national presentation of the disease. The aim of the registry is to improve the management of infective endocarditis, through a better understanding of demographic, clinical, therapeutic and prognostic features of the disease in the real world. The background, rationale, aims and expected results of the registry are reviewed.
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PMID:Infective endocarditis in the real world: the Italian Registry of Infective Endocarditis (Registro Italiano Endocardite Infettiva - RIEI). 1840 5

Recent studies pointed out the increasing rate of infective endocarditis (IE) in diabetic patients. As diabetes mellitus (DM) prevalence is expected to increase in the coming years, infective endocarditis could be more frequently reported in these patients. We here describe a rare case of Enterococcus gallinarum endocarditis developing on normal native heart valve in an elderly diabetic woman. Therapeutic options were restricted due to resistance factors of the microorganism, limited guidance in the medical literature, and the patient's history and underlying condition. Despite these challenges, adequate antibiotic therapy led to the patient's recovery.
Diabetes Res Clin Pract 2008 Jul
PMID:Enterococcus gallinarum endocarditis in a diabetic patient. 1845 97

The aim of this study was to analyze the incidence, topography, and mechanisms of stroke, independent predictors, and late outcome after cardiac valve operations. We retrospectively analyzed prospectively collected data from 2,808 patients (mean age 63 +/- 15 years, n = 1,610, 55% men) who underwent valve surgery with or without concomitant coronary artery bypass grafting from January 1998 to December 2006. Stroke was defined as any new permanent focal neurologic deficit. Overall incidence of stroke was 2.2% (n = 63) and decreased during the study period from 3.3% (1998 to 2002) to 1.3% (2003 to 2006; p = 0.001). The highest stroke rate was observed after double aortic/mitral valve replacement (5.4%) and valve/coronary artery bypass grafting procedures (3.6%). Brain imaging was positive in 74% (n = 43 of 58) and showed ischemic stroke in all patients and hemorrhagic conversion in 28%. Distribution of acute stroke was large territory embolic artery (n = 33, 77%), watershed (n = 7, 16%), and mixed pattern (n = 3, 7%). Multivariate analysis revealed calcified ascending aorta (odds ratio [OR] 2.7), female gender (OR 2.6), ejection fraction <30% (OR 2.3), diabetes (OR 2.2), age >70 years (OR 2.0), and cardiopulmonary bypass time >120 minutes (OR 3.7) as predictors of stroke. Hospital mortality was 24% and 4.6% in patients with and without stroke, respectively. Survival of stroke patients was 78% and 54% at 1 year and 5 years, respectively, and was significantly decreased compared with patients without stroke. Valve pathology including endocarditis did not influence the incidence of stroke. Intraoperative epiaortic scanning may contribute in decreasing the incidence of this complication and may be warranted in all patients undergoing valvular surgery. In conclusion, stroke after valvular surgery is associated with an increased hospital mortality and morbidity and decreased long-term survival.
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PMID:Incidence, imaging analysis, and early and late outcomes of stroke after cardiac valve operation. 1847 60

Elevated troponin is increasingly recognized as a marker of cardiac injury and poor outcomes in diverse disease states. It was hypothesized that patients with infective endocarditis (IE) and elevated cardiac troponin would have more extensive IE and worse clinical outcomes. Patients were enrolled as part of the International Collaboration on Endocarditis (ICE) prospective cohort study; analysis of these patients was done retrospectively. Data from 83 consecutively enrolled patients from a single center were evaluated. Cardiac troponin I (cTnI) was drawn for clinical indications and before any cardiac surgery in 51 of the 83 patients. Outcomes evaluated were hospital mortality, annular or myocardial abscess on the basis of echocardiography or surgery, and central nervous system events. Of 51 patients with cTnI drawn, 33 (65%) had elevated cTnI > or =0.1 mg/dl. There were no differences in age, gender, prosthetic valve IE, Staphylococcus aureus IE, or history of coronary artery disease, congestive heart failure, or diabetes mellitus between patients with and without cTnI elevations. Patients with elevated cTnI were less likely to have isolated right-sided IE and more likely to have left ventricular systolic dysfunction or renal dysfunction (p <0.05 for each). In conclusion, elevated cTnI was associated with the composite of death, abscess, and central nervous system events (p <0.001).
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PMID:Relation of troponin elevation to outcome in patients with infective endocarditis. 1847 61

Pericarditis as a presenting sign of infective endocarditis is rare. Here we describe 2 cases and an additional 19 cases of pericarditis as a presenting sign of infective endocarditis reported during the last 40 y. 71% of patients were young males (mean age 43.2 y). The most commonly reported underlying conditions were diabetes mellitus type 2 (5 patients, 24%), and substance or alcohol abuse (4 patients, 19%). The native aortic valve was the most frequently involved valve. The most common symptoms were fever, cough or dyspnoea, and chest pain. Overt tamponade was diagnosed in 47% of the patients. However, pulsus paradoxus and pericardial friction rub were rare. A heart murmur was heard in 12 patients (57%). Staphylococcus aureus was the most commonly isolated pathogen concomitantly from blood and pericardial fluid. 16 patients (76%) were operated. Six underwent a pericardial procedure, 5 underwent valve replacement, 4 both, and 1 patient was operated for pseudoaneurysm. Mortality rates were 60% and 31% of patients treated with antibiotics alone versus antibiotics and surgical intervention, respectively. In patients presenting with pericarditis with or without cardiac tamponade, the possibility of infective endocarditis should be considered. Optimal therapy should consist of antibiotics and surgical intervention.
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PMID:Pericarditis as a presenting sign of infective endocarditis: two case reports and review of the literature. 1860 1


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