Myocardial abscess complicating healed myocardial infarction.

An isolated myocardial abscess due to Bacteroides fragilis developed in the scar of a myocardial infarction. Fever, chills and signs of pericarditis were the main clinical features. Mild enteritis 1 week prior to the onset of symptoms related to the abscess was the most likely cause of the bacteremia. The diagnosis was established at thoracotomy, performed because of cardiac tamponade. Thirteen other cases of isolated bacterial myocardial abscess accompanying myocardial infarction have been reported, but all the infarctions were recent. Surgical resection for a suspected myocardial abscess should be considered in view of the high mortality, largely from cardiac rupture.     

Inflammation and pericarditis: Are neutrophils actors behind the scenes?

The morbidity of acute pericarditis is increasing over time impacting on patient quality of life. Recent clinical trials focused especially on clinical aspects, with a modest interest in pathophysiological mechanisms. This narrative review, based on papers in English language obtained via PubMed up to April 2018, aims at focusing on the role of the innate immunity in pericarditis and discussing future potential therapeutic strategies impacting on disease pathophysiology. In developed countries, most cases of pericarditis are referred to as idiopathic, although etiological causes have been described, with autoreactive/lymphocytic, malignant, and infectious ones as the most frequent causes. Apart the known impairment of the adaptive immunity, recently a large body evidence indicated the central role of the innate immune system in the pathogenesis of recurrent pericarditis, starting from similarities with autoinflammatory diseases. Accordingly, the “inflammasome” has been shown to behave as an important player in pericarditis development. Similarly, the beneficial effect of colchicine in recurrent pericarditis confirms that neutrophils are important effectors as colchicine, which can block neutrophil chemotaxis, interferes with neutrophil adhesion and recruitment to injured tissues and abrogate superoxide production. Anyway, the role of the adaptive immune system in pericarditis cannot be reduced to a black or white issue as mechanisms often overlap. Therefore, we believe that more efficient therapeutic strategies have to be investigated by targeting neutrophil-derived mediators (such as metalloproteinases) and disentangling the strict interplay between neutrophils and platelets. In this view, some progress has been done by using the recombinant human interleukin-1 receptor antagonist anakinra.     

The x-ray diagnosis of exudative pericarditis

Venous hypertension of lesser circulation was used as a criterion for differential diagnosis of diffuse lesion of the myocardium and exudative pericarditis. In 57 patients (31 with diffuse myocardial lesion and 26 with exudative pericarditis) the results of assessment of common x-ray symptoms were compared with signs of venous hypertension in this disease. The presence or absence of venous hypertension in the recognition of exudate into the pericardial cavity was emphasized.     

A Prospective Study of the Incidence of Myocarditis/Pericarditis and New Onset Cardiac Symptoms following Smallpox and Influenza Vaccination

Background

Although myocarditis/pericarditis (MP) has been identified as an adverse event following smallpox vaccine (SPX), the prospective incidence of this reaction and new onset cardiac symptoms, including possible subclinical injury, has not been prospectively defined.

Purpose

The study’s primary objective was to determine the prospective incidence of new onset cardiac symptoms, clinical and possible subclinical MP in temporal association with immunization.

Methods

New onset cardiac symptoms, clinical MP and cardiac specific troponin T (cTnT) elevations following SPX (above individual baseline values) were measured in a multi-center prospective, active surveillance cohort study of healthy subjects receiving either smallpox vaccine or trivalent influenza vaccine (TIV).

Results

New onset chest pain, dyspnea, and/or palpitations occurred in 10.6% of SPX-vaccinees and 2.6% of TIV-vaccinees within 30 days of immunization (relative risk (RR) 4.0, 95% CI: 1.7-9.3). Among the 1081 SPX-vaccinees with complete follow-up, 4 Caucasian males were diagnosed with probable myocarditis and 1 female with suspected pericarditis. This indicates a post-SPX incidence rate more than 200-times higher than the pre-SPX background population surveillance rate of myocarditis/pericarditis (RR 214, 95% CI 65-558). Additionally, 31 SPX-vaccinees without specific cardiac symptoms were found to have over 2-fold increases in cTnT (>99th percentile) from baseline (pre-SPX) during the window of risk for clinical myocarditis/pericarditis and meeting a proposed case definition for possible subclinical myocarditis. This rate is 60-times higher than the incidence rate of overt clinical cases. No clinical or possible subclinical myocarditis cases were identified in the TIV-vaccinated group.

Conclusions

Passive surveillance significantly underestimates the true incidence of myocarditis/pericarditis after smallpox immunization. Evidence of subclinical transient cardiac muscle injury post-vaccinia immunization is a finding that requires further study to include long-term outcomes surveillance. Active safety surveillance is needed to identify adverse events that are not well understood or previously recognized.     

Seasonality of trichinellosis in patients hospitalized in Belgrade, Serbia

A retrospective study of the course and outcome of trichinellosis in a series of 50 patients hospitalized at the Institute for Infectious and Tropical Diseases in Belgrade between 2001 and 2008 was performed. Clinical diagnosis of trichinellosis was based upon the patients' clinical history, symptoms and signs, and eosinophilia. The occurrence of cases showed a strong seasonality (P < 0.0001). The incubation period ranged between one and 33 days. The mean time between onset of symptoms and admission was nine days. Family outbreaks were the most frequent. Smoked pork products were the dominant source of infection (76%). Fever was the most frequent clinical manifestation (90%), followed by myalgia (80%) and periorbital edema (76%). 43 patients were examined serologically and 72% of them had anti-Trichinella antibodies. Eosinophilia and elevated levels of serum CK and LDH were detected in 94, 50 and 56% of the patients, respectively. All patients responded favorably to treatment with mebendazole or albendazole, but eight developed transient complications. Trichinellosis remains a major public health issue in Serbia.     

Ischemic colitis

Ischaemic colitis is the most frequent form of mesenteric ischaemia and is most frequently the result of a non-occlusive disease process. Elderly patients, especially those with underlying co-morbid conditions are at greatest risk. The symptoms are often non-specific and diagnosis is usually established upon the clinical setting and colonoscopy with biopsy. In the majority of cases, ischaemic colitis can be treated non-surgically with a successful outcome.     

Presenting symptoms of leprosy at diagnosis: Clinical evidence from a cross-sectional,population-based study

BackgroundLeprosy is associated with different dermatologic and neurologic manifestations within a wide clinical spectrum, causing a great diagnostic challenge. Therefore, we aimed to examine associations between common presenting symptoms of leprosy and stage at diagnosis.Methodology/Principal findingsIn this cross-sectional study, we analyzed population-level data from the Leprosy Management Information System (LEPMIS) in Yunnan, China, from 2010–2020 and enrolled patients with newly detected leprosy. The data of 2125 newly detected leprosy patients, with 5000 symptoms, were analyzed. Numbness (828/5000, 16.56%), erythema (802/5000, 16.04%), Painless nor pruritic skin lesions (651/5000, 13.02%), eyebrow hair loss (467/5000, 9.34%), and tubercles (442/5000, 8.84%) were common symptoms of leprosy. The symptoms related to skin (1935/2533, 76.39%) and leprosy reaction (279/297, 93.94%) were mainly existed in MB group. While the symptoms related to disability (263/316, 83.49%), clinical feature (38/56, 69.09%), and facial features (19/23, 82.61%) were predominantly presented in delayed diagnostic group. Despite low proportions, formic sensation (99/5000, 1.98%), pain (92/5000, 1.84%), pruritus (56/5000, 1.12%), finger contracture (109/5000, 2.18%), muscle atrophy (71/5000, 1.42%), and motor dysfunction (18/5000, 0.36%) were reported during the diagnosis of leprosy. The proportions of skin, skin and nerve, and nerve symptoms as initial symptoms were 33.25%, 44.95%, and 21.80% and as only symptoms were 28.66%, 57.81%, and 13.91%, respectively. In those with physical disability, nerve symptoms were the most frequent symptoms (57.65% and 65.36% for the initial and only symptoms, respectively) compared with skin and skin and nerve symptoms. In the delayed diagnosis group, nerve symptoms were the most frequent symptoms (15.73% and 17.25%) and were associated with the longest diagnostic intervals (mean±SD: 38.88±46.02 and 40.35±49.36 months for initial and only symptoms, respectively) when compared with skin and skin and nerve symptoms.ConclusionsUnderstanding the nature of presenting symptoms and developing symptom awareness campaigns would improve the level of leprosy awareness in the community. As nerve symptoms were related to a higher proportion of physical disability and longer diagnosis interval, we should increase awareness about nerve symptoms. Individuals with nerve symptoms should be considered the target group. Neurology outpatient visits may provide potential screening opportunities, and holding focused training for specialized neurology medical staff would enhance the capacity of the health system to recognize leprosy early.     

Difficulties in diagnosing chronic constrictive pericarditis

This presentation calls attention to the many problems involved in the positive, aetiological and differential diagnosis of chronic constrictive pericarditis. We mention the difficulties in aetiological diagnosis in the absence of an episode of acute pericarditis in the past medical history and the clinical findings similar to vascular decompensated cirrhosis or idiopathic restrictive cardiomyopathy. ECG and two-dimensional echocardiography do not have an important role in diagnosis, and in the absence of computed tomography and magnetic resonance imaging, chest radiography, especially a lateral view, could establish the diagnosis. A delay in diagnosis creates difficulties in the surgical treatment, but this treatment improves the patient''s condition in the long term more than the short term.     

Acute liver failure: a rare clinical presentation of visceral leishmaniasis

We recently re-examined a case of Visceral Leishmaniasis, in a 36-year-old caucasian immune-competent men with an unusual clinical presentation. Together with symptoms and signs of a severe acute liver involvement, he presented weight loss, huge spleen enlargement, pancytopenia and increased ?-globulin serum level with a high polyclonal peak. He had no fever, but over-abundant night sweats were frequent. The patient was considered to have liver cirrhosis, and the diagnosis of visceral leishmaniosis was made with a year's delay. From this case report we may learn that, despite an unusual clinical presentation, the diagnosis of visceral leishmaniasis should not be excluded when other characteristic signs and symptoms and laboratory abnormalities are present.     

Clinico-morphologic analysis of subacute sclerosing panencephalitis in patients up to the 19th year of life

Deaths of patients with the subacute sclerosing panencephalitis were analysed in the non-selected autopsy material within 1976-1985. Fifteen cases of the disease, i.e. 0.12% of all autopsies and 3.8% of autopsies in the age group between 1 and 19 years, were noted. Fourteen cases of the subacute sclerosing panencephalitis were noted in the age group of 5-14 years. Mean age was 9.3 years. The disease was nearly three-fold more frequent in male patients. Time lapse between measles infection or antimeasles vaccination and hospitalization for the subacute sclerosing panencephalitis was 4.2 years for both sexes and was much lower for male patients--2.9 years. Morphological lesions characteristic for the subacute sclerosing panencephalitis were seen in the white matter and cortex of the brain in all examined patients. Lesions to the basal ganglia were noted in 9 cases, and additionally to the brain stem and vermiform lobe in 3 cases. The most frequent clinical symptoms accompanying the subacute sclerosing panencephalitis at the beginning of the hospitalization, other diseases and conformation of the clinical diagnosis with sectional findings are also discussed.     

Early recognition of cardiac tamponade.

Nine patients with cardiac tamponade were seen in an 11-month period. Analysis of the clinical and laboratory data indicated that pulsus paradoxus was the most useful physical sign and echocardiography the most useful investigative technique. Three of nine patients died but in only one was the late recognition of tamponade a possible factor in the outcome. Pericardial fenestrations were required in four patients. Viral pericarditis accounted for the tamponade in three cases. There were two cases each of uremia and malignant disease and one case of tuberculous pericarditis. One other case followed pericardiectomy. In five patients tamponade was the initial manifestation of illness.     

Identification of cytomegalovirus (CMV) infection by different laboratory methods in renal transplant recipients undergoing triple-drug immunosupressive treatment.

Early diagnosis of CMV infection is very important mainly in transplant recipients because CMV infection is a frequent complication after transplantation. In this work we compared different laboratory methods: ELISA (IgG, IgM), Western blot,shell vial, antigenemia assay (pp65), the immunofluorescent method with epithelial cells from urine (IF), DNA in leukocytes by PCR and DNA in leukocytes by hybridization (HCS) to estimate the most proper method for diagnosis of CMV in renal transplant recipients. This preliminary study showed that HCS, PCR and Western blot are sensitive methods for detecting CMV infection. Using HCS in quantitative variant we obtained a very good correlation between DNA load and clinical symptoms.     

Rare congenital defects of adrenal steroidogenesis

Congenital defects of adrenal steroidogenesis comprises a group of autosomally recessive disorders, which are usually caused by inactivating mutations in single enzymes involved in adrenal steroid biosynthesis. Each of the defects causes different biochemical consequences and clinical features. A different degree of enzyme dysfunction is responsible for a wide range of phenotypic expression even in the same disorder. The basis for the diagnosis of inborn errors of steroidogenesis are often refined methods for steroid determination. Because these defects may result in life-threatening conditions and, if not treated, lead to serious complications, its is essential to consider their presence in a differential diagnosis of various symptoms. Deficiency of 21-hydroxylase, the most common of these disorders, has been recently extensively reviewed. Therefore, this paper discusses the etiopathogenesis, clinical manifestation, biochemical abnormalities and management of other less frequent defects of adrenal steroidogenesis.     

Pericarditis in the course of acute leukemia

Among 140 patients with acute leukemia (AL) diagnosed according to FAB criteria, pericarditis was diagnosed clinically in 5 of them. They were 2 women and 3 men with different types of AL (L2-in one, M2-in one, M3-in one and M4-in two persons). It occurred in one patient at the onset of the disease and was associated with hyperuricemia, in another one--in complete remission, in the third--during partial remission, and in remaining two patients--during induction therapy. In all patients pericarditis was manifested by fever up to 38-40 degrees C, tachycardia and pericardial friction, in 3-heart silhouettes were enlarged. The ECG revealed mainly depression of ST segments. In 1 case only ECG pattern was typical of pericarditis. Clinically the symptoms of right ventricle failure predominated in 3 and of septic shock--in 2 patients. The etiologic factors were: Pseudomonas aeruginosa 2 X, Enterobacter cloacae 1 X, tuberculosis infection 1 X and hyperuricemia and Enterobacter sepsis 1 X. Pericarditis was favourably influenced by treatment with antibiotics, cardiaca and diuretics in 4 patients. One patient died of a sepsis. In no case the patient's death was attributable to pericarditis. The results of postmortem examinations in 79 cases of AL has revealed three additional cases of pericarditis due to tuberculosis infection, Staphylococcus aureus sepsis and aspergillosis.     

Pneumocystis carinii pneumonia and AIDS

An infection with Pneumocystis carinii with clinical symptoms of pneumonia is particularly frequent in patients with AIDS. The authors discuss current knowledge on Pneumocystis carinii pneumonia, including clinical course, possibility of diagnosis, and chemotherapy in patients with AIDS.     

Clinical spectrum of uncomplicated malaria in semi-immune Amazonians: beyond the " symptomatic " vs " asymptomatic " dichotomy

We analyzed prospectively 326 laboratory-confirmed, uncomplicated malarial infections (46.3% due to Plasmodium vivax, 35.3% due to P. falciparum, and 18.4% mixed-species infections) diagnosed in 162 rural Amazonians aged 5-73 years. Thirteen symptoms (fever, chills, sweating, headache, myalgia, arthralgia, abdominal pain, nausea, vomiting, dizziness, cough, dyspnea, and diarrhea) were scored using a structured questionnaire. Headache (59.8%), fever (57.1%), and myalgia (48.4%) were the most frequent symptoms. Ninety-six (29.4%) episodes, all of them diagnosed during cross-sectional surveys of the whole study population (96.9% by molecular technique only), were asymptomatic. Of 93 symptom-less infections left untreated, only 10 became symptomatic over the next two months following diagnosis. Fever was perceived as " intense " in 52.6% of 230 symptomatic malaria episodes, with no fever reported in 19.1% episodes although other symptoms were present. We found significant differences in the prevalence and perceived intensity of fever and other clinical symptoms in relation to parasite load at the time of diagnosis and patient's age, cumulative exposure to malaria, recent malaria morbidity, and species of malaria parasite. These factors are all likely to affect the effectiveness of malaria control strategies based on active or passive detection of febrile subjects in semi-immune populations.     

T-zone lymphoma--clinical symptoms, therapy, and prognosis (author's transl)]

The clinical symptoms, response to therapy, and prognosis of T-zone lymphoma were analyzed in 32 cases. This recently defined lymphoma entity developed relatively quickly with generalized lymphadenopathy and general malaise. Hepatomegaly and/or splenomegaly and skin efflorescence were frequent presenting symptoms. A few patients showed hyperimmune reactions and occasionally severe autoimmune hemolytic anemia. The erythrocyte sedimentation rate was usually markedly elevated. There was sometimes a polyclonal increase in serum immunoglobulin, sometimes a reduction. Blood and bone marrow smears from a few patients showed occasional atypical lymphocytes. A remarkable finding was the frequent involvement of lung or pleura (40.5% of the patients). The prognosis is unfavorable. Most of the patients were in stages III or IV at the time of diagnosis. Massive infiltration of organs, resistance to routine therapy, and decreasing resistance to infection resulted in death soon after diagnosis. The probability of survival was 0.48 in the first year after diagnosis. The prognosis for patients in stages I and II was clearly better than that for patients in stages III and IV.     

Management of uraemic pericarditis.

Of 250 patients undergoing haemodialysis from 1967 to 1974 17 presented with uraemic pericarditis. Seven of these patients who had been transferred early enough to peritoneal dialysis treatment were cured without pericardiectomy (mean survival 18 months (range 6-36); no deaths). Only one patient was cured from his pericarditis by "aggressive haemodialysis." In seven out of 10 patients treated with haemodialysis, pericardiectomy finally had to be performed because of pericardial tamponade (postoperative survival 20 months (range 8-36); one death). Two patients died from pericardial tamponade before surgery. In patients with evidence of uraemic pericarditis frequent peritoneal dialysis with high fluid withdrawal is the treatment of choice, but in cardiac tamponade pericardiectomy should follow a preoperative pericardiocentesis with limited fluid aspiration. Of possible significance in the aetiology of pericarditis were the findings that 10 of the 17 patients had hypertension with cardiac enlargement and that 14 presented with evidence of underdialysis, possibly due to the reuse of dialysis components.     

Scintigraphie myocardique et séquelles de myocardite : présentation d’un cas clinique

Acute and subacute myocarditis are well-defined pathological entities but it is often difficult to identify them because their clinical expression is variable and the diagnosis is histological showing myocardial inflammation associated with degeneration and/or necrosis. Often symptoms are similar to those of acute pericarditis with “chest-crushing” pain that mimics myocardial infarction and prompts practitioners to request angiography, especially when there are cardiovascular risk factors. We report the case of a 61-year-old patient with neither cardiac history nor cardiovascular risk factor who consulted for a long and self-limited atypical chest pain with normal clinical examination and electrocardiogram. Myocardial perfusion scintigraphy showed a non-reversible photopenic area suspected of being a nontransmural necrosis or an artifact. The discovery of inferolateral hypokinesis of left ventricle on echocardiography led to perform a coronary angiography which was finally normal. Cardiac MRI allowed to diagnose scars of a previous episode of myocarditis.     

Microscopic diagnosis of vulvovaginal candidiasis in stained vaginal smears by Dutch general practitioners

OBJECTIVE: To determine the accuracy of the microscopic diagnosis of vulvovaginal candidiasis (presence of [pseudo] hyphae and blastospores) in stained vaginal smears in clinical practice. STUDY DESIGN: General practitioners trained in diagnosing vulvovaginal candidiasis performed microscopy of 324 stained vaginal smears. These smears were sent to the pathologist for confirmation of the microscopic diagnosis of the clinician; cytologic diagnosis by the pathologist was considered the gold standard. RESULTS: In 104 of the 342 cases Candida was established by the pathologist. The clinicians made 24 false positive and 50 false negative diagnoses of Candida. Sensitivity and specificity of the microscopic diagnoses of the clinicians were 52% and 89%, respectively. The most frequent reason for a false positive diagnosis was presence of hairs, whereas the most frequent reason for a false negative diagnosis was understaining of the smear. CONCLUSION: This study shows that even in stained smears it is difficult for clinicians to recognize blastospores and (pseudo)hyphae. Efforts are clearly needed to improve the quality of the clinical diagnosis of vulvovaginal candidiasis.