Delayed diagnosis of urinary tuberculosis

International audienceA 37-year-old man, who had immigrated from Romania 4 years prior, presented to the emergency department after several months of frequent urination and right-sided lumbar pain. Urine microscopy showed leukocytosis and hematuria. His urine bacterial culture was negative and renal function was normal. An abdominal computed tomography (CT) scan showed right kidney abscesses and thickening of the bladder and urethral walls (Figure 1A). He received a diagnosis of complicated upper urinary tract infection (UTI), and was treated with levofloxacin.Six months later, the patient presented again with similar symptoms. Repeat urine culture was negative and he was empirically treated with trimethoprimsulfamethoxazole. One year after initial presentation, the patient still had urinary tract symptoms. Upon receiving a CT scan for a dental abscess, he was found to have apical pulmonary micronodules with centrolobular distribution.Given the low prevalence of UTIs in young men, and the patient's chronic sterile pyuria, failure to respond to antibiotics and pulmonary findings on CT, we suspected genito-urinary tract tuberculosis. He was referred to our infectious disease service. A repeat CT scan showed parenchymal cavitation. Urine testing with auramine staining, showed acid-fast bacilli, and urinary polymerase chain reaction (PCR) and culture were positive for Mycobacterium tuberculosis. We treated the patient with rifampin, isoniazid, pyrazinamide and ethambutol, but he developed partial destruction of renal tissue, ureteral stenosis and severe shrinkage of the bladder (Figure 1B). At 1-year follow-up, he had developed renal impairment, with an estimated glomerural filtration rate of 71 mL per minute.Genitourinary tuberculosis is the third most common site of infection, accounting for 10% of cases. 1 The gold standard for diagnosis is mycobacterial culture from urine, but the organism can take weeks to grow; PCR may provide a quicker diagnosis, with a sensitivity of 89% and a specificity of 95%. 2 Prognosis of genitourinary lesions is poor, as they often lead to persistent lower urinary tract symptoms and renal failure. 1,3,4 Damage is often irreversible, but reconstructive surgery may mitigate persistent symptoms. 1 Clinicians should consider genitourinary tuberculosis in patients who present with sterile pyuria, have risk factors for tuberculosis and fail to respond to standard treatment for UTI.</p

Brain abscess caused by Bartonella henselae associated with arteriovenous malformation

International audienc

The association between macrovascular complications and intensive care admission, invasive mechanical ventilation, and mortality in people with diabetes hospitalized for coronavirus disease-2019 (COVID-19)

International audienceAbstract Background It is not clear whether pre-existing macrovascular complications (ischemic heart disease, stroke or peripheral artery disease) are associated with health outcomes in people with diabetes mellitus hospitalized for COVID-19. Methods We conducted cohort studies of adults with pre-existing diabetes hospitalized for COVID-19 infection in the UK, France, and Spain during the early phase of the pandemic (between March 2020—October 2020). Logistic regression models adjusted for demographic factors and other comorbidities were used to determine associations between previous macrovascular disease and relevant clinical outcomes: mortality, intensive care unit (ICU) admission and use of invasive mechanical ventilation (IMV) during the hospitalization. Output from individual logistic regression models for each cohort was combined in a meta-analysis. Results Complete data were available for 4,106 (60.4%) individuals. Of these, 1,652 (40.2%) had any prior macrovascular disease of whom 28.5% of patients died. Mortality was higher for people with compared to those without previous macrovascular disease (37.7% vs 22.4%). The combined crude odds ratio (OR) for previous macrovascular disease and mortality for all four cohorts was 2.12 (95% CI 1.83–2.45 with an I 2 of 60%, reduced after adjustments for age, sex, type of diabetes, hypertension, microvascular disease, ethnicity, and BMI to adjusted OR 1.53 [95% CI 1.29–1.81]) for the three cohorts. Further analysis revealed that ischemic heart disease and cerebrovascular disease were the main contributors of adverse outcomes. However, proportions of people admitted to ICU (adjOR 0.48 [95% CI 0.31–0.75], I 2 60%) and the use of IMV during hospitalization (adjOR 0.52 [95% CI 0.40–0.68], I 2 37%) were significantly lower for people with previous macrovascular disease. Conclusions This large multinational study of people with diabetes mellitus hospitalized for COVID-19 demonstrates that previous macrovascular disease is associated with higher mortality and lower proportions admitted to ICU and treated with IMV during hospitalization suggesting selective admission criteria. Our findings highlight the importance correctly assess the prognosis and intensive monitoring in this high-risk group of patients and emphasize the need to design specific public health programs aimed to prevent SARS-CoV-2 infection in this subgroup