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Pyogenic liver abscess (PLA) is a potentially life-threatening disease, and early diagnosis may be difficult. In order to provide diagnostic clues and to enhance the prompt management of such cases, we retrospectively investigated the clinical characteristics of PLA during a 3-year period in a tertiary-care hospital. The crude incidence rate of PLA in our study was 446.1 per 100,000 hospital admissions. Male predominance and a mean age of 57.6 +/- 14.4 years were observed. Diabetes mellitus was the most common concomitant disease, and biliary pathologies were the most common predisposing cause of this type of abscess. The most common clinical features were fever, chills, and abdominal pain. Leukocytosis was found in 67.3% of the patients, and the observed C-reactive protein (CRP) values were high. The most common pathogen was Klebsiella pneumoniae. The mortality rate was 6.5%. A complete history, physical examination, evaluation of the white blood cell count and CRP, and the prompt arrangement of imaging studies may lead to an earlier diagnosis. The aggressive performance of image-guided catheter drainage and the appropriate administration of antibiotics may reduce the mortality rate of PLA.
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PMID:Pyogenic liver abscess: a retrospective analysis of 107 patients during a 3-year period. 1637 69

Intravenous immunoglobulin (IVIg) is administered for various indications and generally considered a safe therapy. Most of the adverse effects (AEs) associated with IVIg administration are mild and transient. The immediate AEs include headache, flushing, malaise, chest tightness, fever, chills, myalgia, fatigue, dyspnea, back pain, nausea, vomiting, diarrhea, blood pressure changes, tachycardia, and anaphylactic reactions, especially in IgA-deficient patients. Late AEs are rare and include acute renal failure, thromboembolic events, aseptic meningitis, neutropenia, and autoimmune hemolytic anemia, skin reactions, and rare events of arthritis. Pseudohyponatremia following IVIg is important to be recognized. Renal failure, usually oliguric and transient, occurs mostly on using sucrose-containing products owing to osmotic injury. Among high-risk patients who have a previous renal disease, dehydration, diabetes mellitus, advanced age, hypertension, hyperviscosity, or are treated by other nephrotoxic medications, administration of a non-sucrose-containing IVIg product after accomplishing hydration, in a low concentration and a slow infusion rate while supervising urine output and kidney function, is recommended. Thromboembolic complications occur because of hyperviscosity especially in patients having risk factors including advanced age, previous thromboembolic diseases, being bedridden, diabetes mellitus, hypertension, dyslipidemia, or those receiving high-dose IVIg in a rapid infusion rate. Immediate AEs can be treated by the slowing or temporary discontinuation of the infusion and symptomatic therapy with analgesics, nonsteroidal anti-inflammatory drugs, antihistamines, and glucocorticoids in more severe reactions. Slow infusion rate of low concentration of IVIg products and hydration, especially in high-risk patients, may prevent renal failure, thromboembolic events, and aseptic meningitis.
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PMID:Intravenous immunoglobulin: adverse effects and safe administration. 1639 92

Liver abscess can be caused by bacterial, parasitic, or fungal infection. Amebic abscesses are more common, but pyogenic abscesses account for three quarters of hepatic abscess in developed countries. Most common pathogens of the pyogenic liver abscess are Escherichia coli, Klebsiella pneumoniae, Bacteroides, Enterococci, Streptococci, and Staphylococci. However, liver abscess caused by Salmonella species has rarely been reported. We experienced a case of Salmonella liver abscess which improved after antibiotic therapy and percutaneous drainage. The patient was 52 years-old man who had an episode of intermittent fever, chills and epigastric pain for 2 weeks. He was diagnosed as liver cirrhosis eight years ago and diabetes three years ago. Salmonella group D, non-typhi was cultured from blood and pus from the liver respectively at the same time. With percutaneous drainage and susceptible antibiotic therapy, liver abscess decreased in size with improvements in fever and abdominal pain.
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PMID:[A case of Salmonella liver abscess]. 1663 85

Bilateral emphysematous pyelonephritis is a rare life-threatening condition affecting almost exclusively patients with diabetes mellitus. Symptoms, which include fever, chills, abdominal and flank pain, nausea, vomiting, dysuria and pyuria, usually mimic those of classic pyelonephritis, and thus clinical suspicion for this urgent condition should be raised in every diabetic patient with similar presentation. Computed tomography (CT) remains the gold standard for the diagnosis demonstrating gas in the renal parenchyma, collecting system or perinephric tissue. Treatment, which should be aggressive, is classically surgical, and early nephrectomy is recommended. Percutaneous drainage associated with medical treatment might be an alternative. Successful exclusively medical treatment has been described but is infrequent and is reserved as an alternative for patients in whom surgical intervention is contraindicated. We report a case of bilateral emphysematous pyelonephritis in an 82-year-old female diabetic patient who presented with symptoms of typical pyelonephritis. Diagnosis was confirmed by CT, and Escherichia coli was identified as the causative factor. The patient was successfully treated medically with intravenous administration of cefepime and amikacin for 14 days and recovered fully. The therapeutical options for this severe but rare condition are discussed.
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PMID:Nonsurgical treatment of bilateral emphysematous pyelonephritis in a diabetic patient. 1713 98

Intravenous immunoglobulin (IVIg) is administered both for the treatment of immunodeficiencies and for an expanding list of autoimmune diseases. Most adverse effects are mild and transient including headaches, flushing, fever, chills, fatigue, nausea, diarrhea, blood pressure changes and tachycardia. IgA deficiency-related anaphylactic reactions are largely preventable. Late adverse events are rare and include acute renal failure and thromboembolic events. Acute renal failure, usually oliguric and transient, occurs generally in insufficiently hydrated patients and with sucrose-stabilized products due to osmotic injury. Thromboembolic complications occur due to hyperviscosity especially in patients having risk factors including advanced age, previous thromboembolic events, immobilization, diabetes mellitus, hypertension, dyslipidemia or those receiving high-dose IVIg in a rapid infusion rate or excessive dose. Slow infusion rate and good hydration may prevent renal failure, thromboembolic events and aseptic meningitis. In our experience in more than 200 patients receiving IVIg for different autoimmune diseases and near 10000 infusions for relapsing-remitting multiple sclerosis patients, the occurrence of adverse effects was 24-36% after high dose IVIg, most were headaches and all were mild adverse events. We conclude that IVIg is a safe therapy when given in a slow infusion rate in well-hydrated patients, better avoiding patients with known risk factors.
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PMID:Safety of intravenous immunoglobulin (IVIG) therapy. 1731 19

Central venous catheter-related blood stream infection (CRBSI) is a major cause of morbidity and mortality in patients with end-stage renal disease treated with chronic hemodialysis. Risk factors include Staphylococcus aureus nasal colonization, longer duration of catheter use, previous bacteremia, older age, higher total intravenous iron dose, lower hemoglobin and serum albumin levels, diabetes mellitus and recent hospitalization. Symptoms that raise clinical suspicion of bacteremia in chronic hemodialysis patients are fevers and chills. When CRBSI is suspected, blood cultures should be obtained and empirical therapy with broad spectrum intravenous antibiotics initiated. The diagnosis of CRBSI is confirmed by isolation of the same microorganism from quantitative cultures of both the catheter and the peripheral blood of a patient that has clinical features of infection without any other apparent source. Gram-positive cocci, predominantly S. epidermidis and S. aureus, cause bacteremia in two-thirds of cases. Among the various approaches to management of CRBSI, removal and delayed replacement of the catheter, catheter exchange over a guidewire in selected patients, and the use of antimicrobial/citrate lock solutions have all been found to be promising for treatment and/or prevention; however, resolution of issues regarding selection, dose, duration and emergence of antibiotic-resistant organisms with chronic use of antibiotic lock solutions, as well as the safety of long-term use of trisodium citrate lock solutions, await further randomized, multicenter trials involving larger samples of hemodialysis patients.
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PMID:Central venous catheter-related bacteremia in chronic hemodialysis patients: epidemiology and evidence-based management. 1745 59

We describe three cases of thyroid storm who developed sudden cardiorespiratory arrest soon after the administration of propranolol orally. CASE 1: A 43 years old Chinese lady presented with complaints of fever and chills. She had a urinary tract infection and also had signs of overt thyrotoxicosis. She was diagnosed to have thyroid storm and was started on oral propranolol, carbimazole and intravenous hydrocortisone and ceftriaxone. Soon after propranolol was given orally she developed an asystolic cardiorespiratory arrest. CASE 2: A 72 years old Chinese gentleman presented with confusion, fever and rapid atrial fibrillation. He was diagnosed to have thyroid storm and was started on oral propranolol, carbimazole and intravenous hydrocortisone and ceftriaxone. He developed a cardiorespiratory arrest about 6 hours after commencement of therapy. CASE 3: A 48-year-old Chinese gentleman presented with complains of dyspnoea and palpitations. He was diagnosed to have thyroid storm and was started on oral propranolol, carbimazole, intravenous hydrocortisone and antibiotics. About 12 hours after admission, he developed a cardiorespiratory arrest. All three patients developed cardiorespiratory arrest soon after the administration of propranolol orally. We conclude that in selective patients who have low output cardiac failure in association with severe thyrotoxicosis, it maybe advisable to avoid use of a beta blocker. A safer alternative is the use of ultra short-acting beta-blockers, such as intravenous esmolol, with extreme caution.
Exp Clin Endocrinol Diabetes 2007 Jun
PMID:Cardiovascular collapse associated with beta blockade in thyroid storm. 1770 86

To investigate the efficacy and safety of recombinant human epidermal growth factor (rhEGF) in advanced diabetic foot ulcers (DFU) A double-blind trial was carried out to test two rhEGF dose levels in type 1 or 2 diabetes patients with Wagner's grade 3 or 4 ulcers, with high risk of amputation. Subjects were randomised to receive 75 (group I) or 25 mug (group II) rhEGF through intralesional injections, three times per week for 5-8 weeks together with standardised good wound care. Endpoints were granulation tissue formation, complete healing and need of amputation. Safety was assessed by clinical adverse events (AEs) and laboratory evaluations. Forty-one patients were included. After 5-8 weeks of treatment, 83% patients in the higher dose group and 61% in group II achieved useful granulation tissue covering more than 98% of the wound area. At long-term assessment, 13 (56.5%) patients healed in group I and 9 (50%) in group II. The mean time to complete healing in group I was 20.6 weeks (95% CI: 17.0-24.2) and 19.5 weeks (16.3-22.7) in group II. After 1-year follow-up, only one patient relapsed. Amputation was not necessary in 65% and 66.7% of groups I and II, respectively. The AEs rates were similar. The most frequent were sepsis (33%), burning sensation (29%), tremors, chills and local pain (25% each). rhEGF local injection enhances advanced DFU healing and reduces the risk of major amputation. No dose dependency was observed.
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PMID:Intralesional injections of Citoprot-P (recombinant human epidermal growth factor) in advanced diabetic foot ulcers with risk of amputation. 1795 79

Emphysematous or gas-forming infections, a very small percentage of bacterial infections of the urinary tract, attract importance because of their life threatening potential. Herein, we report a 60-year-old Saudi female patient who was a known case of Diabetes mellitus for 15 years. She was admitted with left flank pain of 5 days duration, abdominal distension, nausea, vomiting and chills associated with increased frequency of urine, urgency, and dysuria. She had leukocytosis, high blood sugar, elevated urea and creatinine and pyuria. Urine culture grew Escherichia coli. Ultrasound and CT scan showed left pelvicalyceal dilatation and air in the left kidney and urinary bladder. She was treated with a prolonged parenteral antibiotic course, and insulin, with complete recovery.
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PMID:Gas-forming urinary tract infection. 1894 Jan 28

Infection is the second most common cause of mortality in patients with end stage re-nal disease (ESRD). Following strict aseptic precautions during a hemodialysis (HD) session could reduce dialysis-related infection, thereby reducing mortality and morbidity rates. This retrospective study was undertaken to identify the prevalence of dialysis-related bacteremia, sepsis, and catheter infections during HD at Bahrain Specialist Hospital, Bahrain, after following rigid infection control procedures. All HD sessions performed between January 2004 and December 2007 were included. Strict aseptic precautions were observed for every patient in our dialysis unit. The patients' demographic characteristics as well as presence of hypertension (HTN), diabetes mellitus (DM) and use of immunosuppressive drugs were recorded. Results of culture of dialysis catheter tip were collected for all catheters removed or changed during the study period. Catheter surface culture yielding more than 15 colonies and catheter lumen culture yielding more than 1000 CFU/mL were considered positive. All episodes of rigors, chills, bacteremia, and sepsis were recorded. Overall, a total of 1084 HD sessions performed on 46 patients were studied. The mean age of the study patients was 55.2 years (SE 2.5). Fifty four percent were male, 50% had DM, 85% had HTN and 11% were immunosuppressed. With implementation of strict aseptic precautions no catheter-related infection, bacteremia or sepsis was found. Culture of 50 dialysis catheters showed Diptheroid in three patients, MRSE in two patients and MSSE, Enterobacter, and Klebsiella in one patient each. None of the study patients had signs or symptoms of infection or bacteremia. Our study further indicates that following strict aseptic precautions during HD sessions can reduce, if not eliminate, infection as a major cause of mortality and morbidity.
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PMID:Infection-free hemodialysis: can it be achieved? 1958 20


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