Unusual cardiovascular complications of brucellosis presenting in two men: two case reports and a review of the literature

Introduction: Brucellosis is a zoonosis with worldwide distribution, which is particularly endemic in many countries of the Mediterranean basin. Cardiovascular complications of this disease, such as endocarditis, myocarditis and pericarditis, are very rare, with even fewer cases of myocarditis or asymptomatic pericardial effusion in the absence of concomitant endocarditis being reported. Case presentation: We report two cases of brucellosis in two Caucasian men, aged 17 and 34 years old, with myocarditis and asymptomatic pericardial effusion, respectively. Of note, neither patient had concomitant endocarditis. The disease was confirmed serologically and by blood cultures. Both patients recovered completely after receiving appropriate antibiotic treatment without any sign of relapse during a follow-up of 12 months. Conclusion: These two cases emphasize that in endemic areas Brucella can be considered as a potentially causative agent of idiopathic pericardial effusion or myocarditis, even in the absence of concomitant endocarditis. This possibility could be taken into account particularly in cases where contraction of brucellosis is possible, such as occupational exposure or consumption of unpasteurized dairy products. © 2011 Gatselis et al; licensee BioMed Central Ltd

Risk factors for infections caused by carbapenem-resistant Enterobacterales: an international matched case-control-control study (EURECA)

Cases were patients with complicated urinary tract infection (cUTI), complicated intraabdominal (cIAI), pneumonia or bacteraemia from other sources (BSI-OS) due to CRE; control groups were patients with infection caused by carbapenem-susceptible Enterobacterales (CSE), and by non-infected patients, respectively. Matching criteria included type of infection for CSE group, ward and duration of hospital admission. Conditional logistic regression was used to identify risk factors. Findings Overall, 235 CRE case patients, 235 CSE controls and 705 non-infected controls were included. The CRE infections were cUTI (133, 56.7%), pneumonia (44, 18.7%), cIAI and BSI-OS (29, 12.3% each). Carbapenemase genes were found in 228 isolates: OXA-48/like, 112 (47.6%), KPC, 84 (35.7%), and metallo-beta-lactamases, 44 (18.7%); 13 produced two. The risk factors for CRE infection in both type of controls were (adjusted OR for CSE controls; 95% CI; p value) previous colonisation/infection by CRE (6.94; 2.74-15.53; <0.001), urinary catheter (1.78; 1.03-3.07; 0.038) and exposure to broad spectrum antibiotics, as categorical (2.20; 1.25-3.88; 0.006) and time-dependent (1.04 per day; 1.00-1.07; 0.014); chronic renal failure (2.81; 1.40-5.64; 0.004) and admission from home (0.44; 0.23-0.85; 0.014) were significant only for CSE controls. Subgroup analyses provided similar results. Interpretation The main risk factors for CRE infections in hospitals with high incidence included previous coloni-zation, urinary catheter and exposure to broad spectrum antibiotics

Attributable mortality of infections caused by carbapenem-resistant Enterobacterales: results from a prospective, multinational case-control-control matched cohorts study (EURECA)

Objectives: To assess the mortality attributable to infections caused by carbapenem-resistant Enterobacterales (CRE) and to investigate the effect of clinical management on differences in observed outcomes in a multinational matched cohort study. Methods: A prospective matched -cohorts study (NCT02709408) was performed in 50 European hospitals from March 2016 to November 2018. The main outcome was 30 -day mortality with an active postdischarge follow-up when applied. The CRE cohort included patients with complicated urinary tract infections, complicated intra-abdominal infections, pneumonia, or bacteraemia from other sources because of CRE. Two control cohorts were selected: patients with infection caused by carbapenem-susceptible Enterobacterales (CSE) and patients without infection. Matching criteria included type of infection for the CSE group, hospital ward of CRE detection, and duration of hospital admission up to CRE detection. Multivariable and stratified Cox regression was applied. Results: The cohorts included 235 patients with CRE infection, 235 patients with CSE infection, and 705 non-infected patients. The 30-day mortality (95% CI) was 23.8% (18.8-29.6), 10.6% (7.2-15.2), and 8.4% (6.5-10.6), respectively. The difference in 30 -day mortality rates between patients with CRE infection when compared with patients with CSE infection was 13.2% (95% CI, 6.3-20.0), (HR, 2.57; 95% CI, 1.55 -4.26; p &lt; 0.001), and 15.4% (95% CI, 10.5-20.2) when compared with non-infected patients (HR, 3.85; 95% CI, 2.57-5.77; p &lt; 0.001). The population attributable fraction for 30 -day mortality for CRE vs. CSE was 19.28%, and for CRE vs. non -infected patients was 9.61%. After adjustment for baseline variables, the HRs for mortality were 1.87 (95% CI, 0.99-3.50; p 0.06) and 3.65 (95% CI, 2.29-5.82; p &lt; 0.001), respectively. However, when treatment -related time -dependent variables were added, the HR of CRE vs. CSE reduced to 1.44 (95% CI, 0.78-2.67; p 0.24). Discussion: CRE infections are associated with significant attributable mortality and increased adjusted hazard of mortality when compared with CSE infections or patients without infection. Underlying patient characteristics and a delay in appropriate treatment play an important role in the CRE mortality. (c) 2023 The Authors. Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious Diseases. This is an open access article under the CC BY -NC -ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/)

Δημογραφικά χαρακτηριστικά ασθενών με χρόνια λοίμωξη από τον ιό της ηπατίτιδας Β στην περιοχή της Κεντρικής Ελλάδας

Hepatitis B virus (HBV) infection is a major public health problem and a cause of infectious disease mortality worldwide. It has been estimated that there are 350 million chronic HBV carriers all overthe world. Approximately 2 million people die annually from HBVrelated liver disease, including cirrhosis and hepatocellular carcinoma (HCC). The endemicity of HBV infection varies greatly in different part of the world and is influenced primarily by the predominant age at which infection occurs. In Greece, it has been reported that the prevalence of chronic HBV infection varies considerably by region and high-risk group, ranging from 0.33% in rural children and 0.41-0.85%in volunteer blood donor population in Crete and Epirus to 2.9% among pregnant Greek women and 22% in refugees from southern Albania. Classically, three modes of transmission have been recognized: perinatal, sexual, and parenteral/percutaneous transmission including injection drug use, transfusion of blood or blood products, dialysis, needle sticks or other injuries while working in health care settings, acupuncture and tattooing. Person to person spread of HBV can occur in settings involving non-sexual interpersonal contact over a long period of time (intrafamilial transmission). In Greece, there is few data on the epidemiological characteristics ofHBV infection. The aims ofthis study were: To investigate for the epidemiological patterns ofthe HBV infection in Thessaly, To identify the possible differences in the HBV prevalence (clusters) between areas inside this geographic field. Vertical and intrafamilial modes of transmission are the major routes of HBV infection in this study. Of note, about 20% of our patients have a positive family history of jaundice or other liver disease. Thessaly is mainly a rural region of Greece (census 2001), and rural families are more crowded and this may be increasing the intrafamilial mode oftransmission. Greece is still a country with intermediate seroprevalence of HBV infection. Most of infections occur during early childhood and since over 90% of childhood infections are asymptomatic, these individuals have not clinically apparent disease. In this report, patients with perinatally acquired infection had remained without diagnosis for about 38 years. This is very important from the public health point of view, as these patients during that period have active sexual behavior (in this study 16.5% referred multiple sexual partners), tend to use health services and are in general active members of the community. It is obvious that they represent a «silent reservoir» of the infection that due to the ignorance of the problem, it is uncertain how they truly account for the maintenance of HBV infection in this area. We found that alcohol abuse is frequent among patients with chronic HBV infection and moreover, it is an independent risk factor for cirrhosis or HCC development apart from HBV infection (OR: 2.5, Cl: 1.24-5.18%, p=0.01). The overall HAV seroprevalence described in the present study(80.4%) is higher than that found in recent studies from Greece in the general population or in special occupational groups. Educational level of elementary school (OR: 11, p=0.000001), rural residence (OR: 3, p=0.006) and age groups 41-50 (OR: 3.8, p=0.03), 51-60 (RR: 1.3, p=0.0004) and 61-70 years (RR: 1.3, p=0.003) were independent factors among patients with chronic HBV infection which predict prior HAV exposure. Moreover, all subjects older than 50 years were anti-HAV positive, but significantly high percentages were found in younger patients as well. The above information could be easily explained by the fact that the educational level of the studied patients is generally low. Additionally, Central Greece is a region with high proportion of rural population and is characterised by recent urbanization that was developed the last 25 years. Thus, the results of improved sanitation and hygienic standards will be obvious in the future years. In addition, we identified differences in the frequency of HBV infection between municipalities of Central Greece. These results can contribute to the mapping ofthe infection in distinct geographical areas. It is of great importance from the public health point of view that the presence of the infection in the municipalities of Verdikousia, Potamia, Sarantaporo and Koilada is high taking into account either the connection with the origin or the residence of the affected individuals. In Greece, such clusters of high HBV prevalence have already been reported. In the municipality of Koilada, the presence of HBV infection was associated with sexual transmission (p=0.02), in the municipality of Potamia with vertical transmission (p=0.003, Fisher’s exact test) and in the municipality of Smiksi with folk remedies (p=0.04, Fisher’s exact test). Additional extended studies ofthe general population in Thessaly are necessary in order to create a well-designed control program, until the cohorts of vaccinated children reach adolescence and adulthood.Ο HBV δεν είναι κυτταροπαθογόνος ιός και ανήκει στους hepadna ιούς. Παγκοσμίως συμβαίνουν 2.000.000 θάνατοι ανά έτος οφειλόμενοι στον HBV, το μεγαλύτερο ποσοστό των οποίων συνδέεται με τις μακροχρόνιες επιπλοκές της χρόνιας ηπατίτιδας Β (κίρρωση, πυλαία υπέρταση, ηπατοκυτταρικό καρκίνωμα). Ο HBV αποτελεί τη δεύτερη μετά το κάπνισμα συχνότερη αιτία καρκινογένεσης (80% των ηπατοκυτταρικών καρκίνων σχετίζεται με τον HBV). Η Ελλάδα παρουσιάζει ενδιάμεση ενδημικότητα λοίμωξης από τον HBV, δηλαδή συχνότητα HBsAg 2-7% και συχνότητα δεικτών προηγούμενης λοίμωξης (αντί-HBs και αντί-HBc) 20-50%. Η μετάδοση του ιού γίνεται κυρίως παρεντερικά ή διαδερμικά. Άλλοι τρόποι μετάδοσης αποτελούν η σεξουαλική επαφή και η κάθετη μετάδοση από μητέρα φορέα στο νεογνό (κατά τη διάρκεια του τοκετού ή πολύ πιο πιθανά κατά την περιγεννητική περίοδο). Στις ενδιάμεσης ενδημικότητας χώρες, όπως η Ελλάδα, η μετάδοση αφορά σε όλες τις ηλικίες, αλλά η πρώιμη παιδική ηλικία φαίνεται να είναι η ομάδα με τον υψηλότερο κίνδυνο. Η ανάλυση του επιπολασμού της ηπατίτιδας Β στην Ελλάδα είναι δύσκολη, γιατί: • Υπάρχουν μεγάλες διακυμάνσεις ακόμα και σε γειτονικές περιοχές • Υπάρχουν διαφορές ανάλογα με την ηλικιακή σύνθεση των εξεταζόμενων πληθυσμών • Έλεγχος μεγάλης κλίμακας σε γενικό πληθυσμό (όχι αιμοδότες) δεν έχει γίνει. Σκοπός της παρούσας μελέτης ήταν: > Η καταγραφή για πρώτη φορά των δημογραφικών χαρακτηριστικών της χρόνιας λοίμωξης από τον HBV στην Κεντρική Ελλάδα, έτσι ώστε να διαφανεί το πρότυπο της λοίμωξης από τον HBV σε αυτό το τμήμα του Ελλαδικού χώρου (ηλικία, φύλο, παράγοντες κινδύνου, κύριος τρόπος μετάδοσης, διάρκεια λοίμωξης). > Η ανάδειξη τυχόν θυλάκων του νοσήματος μέσω της επίτευξης της γεωγραφικής κατανομής της λοίμωξης. Η λεπτομερής αποτύπωση της γεωγραφικής κατανομής της χρόνιας λοίμωξης από τον HBV είναι εξαιρετικά σημαντική από επιδημιο λογικής άποψης, γιατί τα αποτελέσματα μπορούν να χρησιμοποιηθούν από τις κεντρικές υπηρεσίες υγείας προς την κατεύθυνση της πρόληψης-παρέμβασης και της σωστής αγωγής υγείας. Βρέθηκε ότι η κάθετη και η ενδοοικογενειακή μετάδοση της λοίμωξης είναι οι δύο κυριότερες οδοί διασποράς του HBV στη χώρα μας τις προηγούμενες δεκαετίες (201/303 ασθενείς στην παρούσα μελέτη). Η σεξουαλική μετάδοση της λοίμωξης συσχετιζόταν με το άρρεν φύλο (OR: 2, ρ=0,04), ενώ στατιστικά σημαντική διαφορά βρέθηκε μεταξύ του ανδρικού φύλου και των πολλαπλών σεξουαλικών συντρόφων στο παρελθόν (OR: 28, ρ=0,000005). Ο μέσος όρος ηλικίας των ασθενών με πιθανολογούμενη πηγή λοίμωξης την κάθετη μετάδοση ήταν 35,11 ±15,44 έτη, αλλά η μέση διάρκεια της γνωστής λοίμωξης ήταν μόλις 5,68±5,35 έτη. Δηλαδή, παρέμειναν αδιάγνωστοι επί 38 περίπου έτη κατά μέσο όρο. Κατά τη διάρκεια αυτών των ετών οι ασθενείς αυτοί, όντας ενεργά μέλη της κοινότητας, ενδεχομένως μεταδίδουν τη λοίμωξη μέσω των ερωτικών δεσμών που συνάπτουν ή προσφεύγοντας στις υγειονομικές υπηρεσίες (χειρουργικές ή οδοντιατρικές επεμβάσεις, εισαγωγές σε νοσοκομεία ή κλινικές). Είναι προφανές ότι οι ασθενείς αυτοί αποτελούν μία «σιωπηλή δεξαμενή» της λοίμωξης. Βρέθηκε ότι δεν υπάρχει στατιστικώς σημαντική συσχέτιση μεταξύ της πηγής λοίμωξης, της κατανάλωσης οινοπνεύματος, της ηλικίας και της διάρκειας λοίμωξης με τους ασθενείς που βρίσκονταν στην κλινική φάση της ηπατίτιδας ή της «χρόνιας φορείας» από τον HBV. Αντίθετα, η κατανάλωση οινοπνεύματος είναι ο μοναδικός ανεξάρτητος παράγοντας σε σχέση με την ηλικία καθώς και τη διάρκεια και την πηγή της λοίμωξης που επηρεάζει την εξέλιξη της νόσου σε κίρρωση ή ανάπτυξη ηπατοκυτταρικού καρκίνου (OR: 2,5, CI: 1,24- 5,18%, ρ=0,01). Στην παρούσα μελέτη, το συνολικό ποσοστό προηγηθείσας λοίμωξης από ηπατίτιδα A (80,4%) ήταν σημαντικά υψηλό. Η λοίμωξη με τον HAV στους ασθενείς με χρόνια ηπατίτιδα Β συσχετίστηκε θετικά με ηλικίες ασθενών άνω των 50 ετών, την αγροτική κατοικία και το χαμηλό μορφωτικό επίπεδο. Παρ’ όλα αυτά, ο επιπολασμός της οροθετικότητας για αντί-HAV IgG αντισώματα είναι σχετικά υψηλός ακόμα και στις μικρές ηλικίες, αντανακλώντας το σχετικά χαμηλό μορφωτικό επίπεδο των ασθενών του δείγματος αλλά και τη διαρκή ανάγκη βελτίωσης της ύδρευσης και των συνθηκών υγιεινής στα μελλοντικά έτη. Στην παρούσα μελέτη αποτυπώνεται επίσης για πρώτη φορά η γεωγραφική κατανομή της λοίμωξης από τον HBV στην Κεντρική Ελλάδα. Οι περιοχές της Βερδικούσιας, του Σαρανταπόρου, της Κοιλάδας και της Ποταμιάς εμφανίζουν αυξημένη συχνότητα λοίμωξης τόσο σε σχέση με την καταγωγή όσο και με την κατοικία. Ο δήμος Κοιλάδας συσχετίστηκε με τη σεξουαλική μετάδοση (ρ=0,02), η κοινότητα της Σμίξης με τις παραδοσιακές πρακτικές (ρ=0,04, Fisher’s exact test), ο δήμος Ποταμιάς με την κάθετη μετάδοση (ρ=0,003, Fisher’s exact test) της λοίμωξης από τον HBV. Είναι σημαντικό ότι η γεωγραφική κατανομή της λοίμωξης από τον HBV στην Κεντρική Ελλάδα δεν παρουσιάζει σημαντικές μεταβολές αναλύοντας πληροφορίες μεγαλύτερου δείγματος ασθενών του Ηπατολογικού Ιατρείου (η=921). Αυτό πιθανώς να αναδεικνύει το μέγεθος του προβλήματος στις περιοχές υψηλής συχνότητας. Περαιτέρω μελέτες στις εν λόγω περιφέρειες αλλά και στο γενικό πληθυσμό είναι απαραίτητες για την καλύτερη εκτίμηση του προβλήματος της χρόνιας λοίμωξης από τον HBV στην Κεντρική Ελλάδα

Spontaneous spondylodiscitis: presentation, risk factors, diagnosis, management, and outcome

SummaryBackgroundSpontaneous spondylodiscitis is an uncommon disease, which may result in serious complications with potentially high morbidity and mortality. We conducted a prospective case study over a 2-year period in order to analyze the clinical features, approaches to management, and outcome of spondylodiscitis.MethodsEight consecutive patients (four men, four women; age range 53–82 years) suffering from spondylodiscitis were identified during the study period. Parameters recorded included: demographics, past medical history, predisposing factors, presenting signs and symptoms, spinal level and extension of the infection, laboratory indices of inflammation, microbiological testing, radiological assessment, kind and duration of treatment, follow-up magnetic resonance imaging (MRI) studies, and outcome.ResultsDuration of symptoms varied from 14 to 90 days. All patients had back pain; fever ≥38°C was present in 5/8 (62.5%) and neurological findings in 6/8 (75%). Diabetes mellitus was identified in six (75%). Most of the patients had elevated laboratory markers of inflammation. At the initial MRI, 12 anatomical levels were found. The microorganism was identified in 7/8 by blood or bone marrow cultures (50% Staphylococcus aureus). None of the patients underwent surgical intervention. Seven patients (87.5%) recovered to full activity; follow-up MRI study results were not always in parallel with the clinical improvement of patients.ConclusionsSpontaneous spondylodiscitis should be considered in every patient with back pain accompanied by fever and laboratory markers of inflammation. The major predisposing risk factor seems to be uncontrolled diabetes. MRI appears to be the method of choice for confirming diagnosis. Timely and accurate diagnosis along with prompt administration of antibiotics appears mandatory for a favorable outcome and avoidance of surgical intervention

Current clinical, laboratory, and treatment outcome characteristics of visceral leishmaniasis: results from a seven-year retrospective study in Greece

SummaryObjectivesVisceral leishmaniasis (VL) is re-emerging in endemic areas. The epidemiological, clinical, laboratory, and treatment outcome characteristics in a large cohort of VL patients is described herein.MethodsThe cases of 67 VL patients (57% male, mean age 56 years) treated in two Greek hospitals over the last 7 years were identified and evaluated retrospectively.ResultsForty-six percent of patients reported contact with animals. Seventeen patients (25%) were immunocompromised, and 22% were co-infected with another pathogen. Sixty-four percent of patients had fever, 57% had weakness, 37% had sweats, 21% had weight loss, and 13% had a dry cough, while 6% developed haemophagocytic syndrome. The median duration of symptoms was 28 days. Fifty-eight percent of patients had splenomegaly, 49% had hepatomegaly, and 36% had lymphadenopathy. The diagnosis was established by positive PCR in peripheral blood (73%) and/or bone marrow specimens (34%). Sixty-one patients (91%) received liposomal amphotericin (L-AMB). Six patients (10%) did not respond or relapsed but were eventually cured after a second cycle of L-AMB. During a 6-month follow-up, the overall mortality was 9%, although none of these deaths was attributed to VL.ConclusionsVL is still a common disease in endemic areas, affecting immunocompetent and immunocompromised patients. Its diagnosis is challenging, and molecular techniques are valuable and helpful tools to achieve this. Treatment with L-AMB is safe and very effective