Brucellosis is a commonly diagnosed zoonosis and neurological involvement is rare. A 30-year-old woman presented with a pulsatile headache that was exacerbated by the Valsalva maneuver and refractory to analgesic therapy. The patient also had nausea, cough, and coryza that evolved over 7 days. The neurological examination was unremarkable. Thrombosis of the lateral and sigmoid sinus and ipsilateral internal jugular vein were diagnosed and anticoagulation therapy was started. Brucella spp was identified in a sample of cerebrospinal fluid (CSF); five months after treatment with rifampicin and doxycycline, CSF was sterile. Cerebral venous thrombosis is a very uncommon sign of brucellosis.
<p><strong>Introduction:</strong> Severe sepsis and septic shock are common conditions with high levels of morbi-mortality surpassing those of coronary heart disease or stroke. The reality of hospital treated sepsis is largely unknown outside of the intensive care unit. We therefore aimed to evaluate the level of compliance with the Surviving Sepsis Campaign 6-hour bundle in a Portuguese emergency department and to relate it to the patient clinical outcomes. </p><p><strong>Material and Methods:</strong> We conducted a retrospective, observational cohort study with 178 severe sepsis/septic shock patients admitted to the intensive and intermediate care unit between January 1st 2012 and December 31st 2012.</p><p><strong>Results:</strong> In the study, period septic shock was diagnosed in 100 patients (56.2%) and severe sepsis in 78 patients (43.8%). Compliance with the sepsis bundle was: (1) 62.9% for lactate measurement; (2) 62.9% for blood cultures before antibiotics; (3) 41.6% for antibiotics in the first 3 hours; (4) 76.4% for fluid administration; (5) 25% for vasopressor administration; (6) 37% for central venous pressure measurement and (7) 39% for central venous oxygen saturation measurement. Full compliance was observed in 22% of the patients. The individual bundle measure - Blood cultures before antibiotics - was significantly associated with a decreased risk of both intensive care unit mortality and 28-day mortality. There was also a trend for an inverse correlation between increased compliance with the full bundle and the intensive care unit and 28-days hospital mortality.</p><p><strong>Discussion:</strong> There was a low compliance with the Surviving Sepsis Campaign 6-hour bundle, a result that replicates the findings in similar international studies. The explanation is complex but it may include the lack of institutional quality monitoring in the emergency department.<br /><strong></strong></p><p><strong>Conclusions:</strong> The compliance with a sepsis resuscitation bundle starting in the emergency department was positively associated with the outcomes of the septic patients. Nonetheless the bundle was unreliably performed.</p><p> </p>
A 47-year-old man, 20 pack-per-year smoker, and heavy alcohol drinker, with an episode of pulmonary tuberculosis 10 years previously, presented to the Emergency Department with 7 days of cough, mucous sputum, and abdominal pain. Additionally, he presented with 5 days of a pruriginous skin rash that started on the thorax but rapidly disseminated to the entire body, and with 3 days of fever. Physical examination revealed dyspnea, polypnea, fever, dispersed ronchi bilaterally upon chest auscultation, and dispersed papules, pustules, and hemorrhagic vesicular lesions on the skin and oral mucosa ( Figures 1 and 2).A thoracic computed tomography scan showed peribronchovascular parenchymatous densities with areas of groundglass opacity, suggesting an infectious process with endobronchial dissemination (Figure 3). Fiberoptic bronchoscopy showed scattered ulcerated and vesicular lesions in the airway lining. Blood tests showed cytolytic hepatitis and rhabdomyolysis. Despite treatment with acyclovir, ceftriaxone, and azithromycin, the patient deteriorated rapidly and exhibited severe acute respiratory distress syndrome, with a PaO2/FiO2 ratio of 95 mmHg. At this point our patient was transferred to the intensive care unit to be started on mechanical ventilation, hemodialysis for acute kidney injury, norepinephrine cardiovascular support for septic shock, and extracorporeal membrane oxygenation, which he continued for 20 days. The sepsis workup from admission was sterile for bacteria, fungi, and mycobacteria; serology studies for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative; and no relevant immunosuppression factors could be identified. Serologic tests were positive for varicella zoster virus (VZV)-specific immunoglobulin G and immunoglobulin M, determined by enzyme-linked immunosorbent assay and enzyme-linked fibrinolytic assay. The serum was also positive for VZV deoxyribonucleic acid, determined by polymerase chain reaction. Because our patient had no known history of chickenpox, and had never been vaccinated for VZV, we made the diagnosis of primary VZV infection. By day 35 after admission, our patient had improved sufficiently and was transfered to the medical ward. DISCUSSIONChickenpox is usually a benign disease, but in immunocompromised individuals it can lead to clinical complications with significant morbidity and mortality. 1 VZV infection causes primarily chickenpox, which is characterized by a typically disseminated skin rash. 2 Lung infection because of VZV is uncommon, and it usually occurs two to seven days after the appearance of skin rash. The initial cutaneous lesions of varicella often involve the scalp, face, and/or trunk and are pruritic, erythematous macules. The maculopapular phase of infection evolves to a vesicular phase, during which fluid-filled vesicles
ResumoApresenta-se um caso clínico de pericardite por Mycobacterium tuberculosis, que condicionou um estado de pré-tamponamento cardíaco. Apesar dos progressos dos últimos anos, Portugal continua a ser o único país da Europa Ocidental com uma taxa intermédia de infeção por Mycobacterium tuberculosis. A infeção é adquirida por via respiratória e pode disseminar-se e instalar-se em qualquer órgão durante a primoinfeção ou em outra qualquer altura em que haja imunodepressão do indivíduo. O atingimento pleural é o mais comum e o pericárdico é raro, representando apenas 1-2% dos doentes com tuberculose. No presente caso clínico torna-se evidente a importância de uma abordagem sistematizada e holística dos doentes com pericardite durante a sua investigação etiológica. Palavras chave: Pericardite, Mycobacterium tuberculosis, Pericardiocentese, Antituberculosos. AbstractWe report an interesting case of tuberculous pericarditis that evolved to a cardiac pre-tamponade. Portugal is still the only country in Western Europe with an intermediate rate of Mycobacterium tuberculosis infection. The infection is acquired by inhalation and can disseminate to any body organ during primary infection or at any other time where there is immunodepression of the patient. Pleural involvement is the most common and pericardial involvement is rare with just 1-2% of the patients with pulmonary tuberculosis. In this clinical case we evidence the importance of a systematized approach to these patients during the etiological investigation. Key-Words: Pericarditis, Mycobacterium tuberculosis, Pericardiocentesis, antituberculosis chemotherapy. IntroduçãoA pericardite é um diagnóstico raro, representando 0,1% das admissões hospitalares. Reflete um processo inflamatório que atinge o pericárdio, com eventual acumulação de líquido na cavidade pericárdica 1,2 . Determinar a etiologia da pericardite é sempre um desafio. A maioria é idiopática, seguindo-se as causas neoplásica e infeciosa 3 . Relativamente à última etiologia, a incidência dos diferentes agentes infeciosos varia significativamente de acordo com a população em estudo, nomeadamente com a prevalência de doentes imunocomprometidos e em particular com a de VIH positivos. De uma maneira geral, os vírus são os mais comummente implicados, seguidos pelas bactérias e muito mais raramente fungos e parasitas. Dentro das bactérias, o Mycobacterium tuberculosis (MT) é o agente etiológico mais comum (4-5%) 1,3,4 . Nas populações de doentes com VIH, a pericardite por MT é mesmo a etiologia mais comum, ultrapassando até a idiopática 3,5 . Portugal continua a ser o único país da Europa Ocidental com uma taxa intermédia de infeção por MT 6 . A infeção por MT é adquirida por via respiratória e pode disseminar-se e instalar-se em qualquer órgão durante a primoinfeção ou em outra qualquer altura em que haja imunodepressão do indivíduo. O atingimento pleural é o mais comum e o pericárdico é raro, representando apenas 1-2% dos doentes com tuberculose 7,8 . A tuberculose pericárdica (TP) é uma patologia de difíc...
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