IntroductionIn the pre-antibiotic era up 10% of cases of infective endocarditis were due to Streptococcus pneumoniae, but this association is currently exceedingly rare.Case descriptionSince 1997 we have diagnosed three patients, all aged >70, with endocarditis due to S. pneumoniae. One of these three cases involved a prosthetic valve, another a prosthetic ring. All three patients completely recovered with antibiotic treatment only.Discussion and evaluationDuring the same period there were 1694 cases of pneumococcal bacteremia, of whom 395 (23%) after age 70. Therefore, after age 70 the prevalence of endocarditis out of all cases of pneumococcal bacteremia was 0.7%. A literature review detected another 16 cases of pneumococcal PVE. The mean age of these 17 patients was 64±14; 10 were female and 7 male. In most instances, symptom duration was short, < 6 days. Valve surgery was performed in 5 cases (29%) and 13 patients (76%) survived.ConclusionsEndocarditis due to S. pneumoniae is rare in the antibiotic era; even in patients with prosthetic valves its course is evidently not more virulent than with other low-virulent organisms.
Background The short Synacthen test (SST) is widely used to assess the hypothalamus−pituitary−adrenal axis in the outpatient setting. However, in the inpatient setting, technical difficulties to adhere to the protocol may pose a challenge for using this test. Aims To find the most suitable basal serum cortisol (BSC) cut‐off for predicting an adequate response to the SST in non‐critically inpatients without conducting the actual test. Methods Information was retrieved retrospectively from medical files of 197 patients who had had a 250 μg SST between the years 2000 and 2016 at the Shaare Zedek Medical Center. BSC, electrolytes, creatinine, thyroid‐stimulating hormone, blood counts and blood pressure values were evaluated for a correlation with the results of the SST. Results A BSC cut‐off of 280 nmol/L provides a negative predictive value of 94% for adrenal insufficiency (AI). Using a cut‐off of 380 nmol/L increases the sensitivity to 96% and yields a negative predictive value of 95.8%. Conclusions In this study, we found two suitable BSC cut‐offs for predicting an adequate response to the SST in hospitalised patients. We suggest using the lower cut‐off (280 nmol/L) for patients with a low level of suspicion for AI and using the higher cut‐off (380 nmol/L) for patients with a higher level of suspicion. A BSC above this cut‐off makes the diagnosis of AI very unlikely and precludes the need for a Synacthen test.
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