An ongoing trend in medicine toward evidence-based practice emphasizes efficiency and algorithmic approaches toward diagnosis and treatment. This approach has a number of potential benefits including cost-savings, standardization of practice, and improvement in quality of care. 1 A proliferation of clinical scoring systems has in part been a consequence of this movement. These scoring systems are designed to inform clinical decision-making and may involve tools for diagnosis (eg, Wells Criteria), prognosis of disease (eg, the Model for End-Stage Liver Disease score), and future risk of developing a disease (eg, Atherosclerotic Cardiovascular Disease risk score).Clinical scoring systems vary from those that are widely recognized and used (eg, National Institutes of Health Stroke Scale, APGAR [Appearance, Pulse, Grimace, Activity, Respiration]) to those that are highly specialized and used less commonly (eg, A 2 DS 2 [age, atrial fibrillation, dysphagia, sex, and severity]). However, there has been a large recent increase in scoring systems without evidence of any clear clinical benefit for most. Each week, new scoring systems are published in the medical literature. In this Viewpoint, we assess this phenomenon and explore the clinical usefulness of these scores.A search of the MEDLINE/PubMed database using various search terms (eAppendix in the Supplement) to identify peer-reviewed articles related to clinical scoring systems resulted in approximately 250 000 publications since 1965, with an almost exponential increase in yearly publications of scoring systems over time (Figure). Until the mid-1990s, fewer than 5 publications per 1000 total publications were identified, whereas in 2018, more than 20 publications per 1000 publications were identified.
A 61-year-old man with relapsing chronic lymphocytic leukaemia, status post allogeneic stem cell transplant and multiple chemotherapy regimens presented to the emergency room after suffering a grand mal seizure. His evaluation revealed a 1.5-2 cm ring-enhancing left temporal lobe brain lesion on the CT scan. This brain lesion was resected and the histopathology revealed an invasive fungal organism resembling mucormycosis. Amplification and sequencing of the 28S ribosomal RNA gene identified the organism as The patient was treated with liposomal amphotericin B 5 mg/kg every 24 hours for 4 weeks, and then was transitioned to oral posaconazole. Serial brain imaging at 1 and 3 months, while on therapy, showed significant improvement.
Histoplasma capsulatum is an endemic fungus that most oftenly causes a self‐limiting illness but can result in severe infections in immunocompromised patients including pulmonary or extra‐pulmonary disease. Rarely it can also cause a chronic progressive infection of the larynx. Herein, we report a case of laryngeal histoplasmosis in a kidney transplant patient who presented with progressive symptoms of several weeks of hoarseness, dysphagia and odynophagia. Laryngoscopic examination revealed thick plaques in the oropharynx with surrounding hyper‐erythema and histopathology showed numerous intracellular yeasts forms consistent with H capsulatum. Patient was initiated on treatment with itraconazole. Infection of the larynx due to H capsulatum is highly uncommon and therefore can result in an inappropriate or delayed diagnosis. A review of literature showed four previously reported cases of laryngeal histoplasmosis in patients with solid organ transplant. This is the first case series of laryngeal histoplasmosis in transplant recipients.
A 70-year-old man with non-ischaemic dilated cardiomyopathy presented with symptoms of fatigue, chills and unintentional weight loss over the past 2 months. Initial evaluation revealed anaemia, peripheral leucocytosis and elevated inflammatory markers. Results of an oesophagogastroduodenoscopy, colonoscopy, blood bacterial and fungal cultures and bone marrow biopsy were negative. An F-FDG positron-emission tomography-CT demonstrated an indeterminate, intensely FDG-avid 5 cm × 2 cm × 5.6 cm × 6.7 cm mass centred within the junction of the superior vena cava and right atrium, suggestive of probable malignancy versus an inflammatory thrombus. After multidisciplinary consideration, patient underwent a diagnostic minithoracotomy and a thick fibrotic mediastinal mass was visualised and evacuated. The encapsulated mass contained thick, white creamy liquid that appeared to be purulent/necrotic material. The biopsies of the capsule wall on frozen section demonstrated fungal elements consistent with Aspergillosis species. Fungal culture confirmed diagnosis of.
In this report, we describe three cases of rare oncologic metastases. The first patient was a 73-year-old male, diagnosed with metastatic male breast cancer after radiological investigation of suspected renal cell carcinoma. The other two male patients, a 69 and 73-yearold, were diagnosed with colon adenocarcinoma; suspected to be a second primary prostate carcinoma following Positron Emission Tomography-Computer Tomography (PET-CT). This suspicion was ruled out by prostatectomy and histopathological investigations, which instead found adenocarcinoma of colonic origin. Keywords: rare metastasis; colon cancer; male breast cancer; second primary; adenocarcinoma
Background Stenotrophomonas maltophilia is a hospital acquired infection that is associated with high morbidity and mortality. There has been a reported rise in S. maltophilia infections, presumed secondary to the increase in the population at risk.MethodsWe retrospectively reviewed all hospitalized adult patients in Mayo Clinic, MN with S. maltophilia bacteremia from January 2008 through January 2018. We analyzed patient population and described patients at risk, sources of infection, and changes in antimicrobial susceptibility profile.ResultsA total of 94 patients were analyzed, including 52 males, median age of 56 (46–65.75 IQR). The population included 60 infections in those with malignancies and 30 infections in transplant recipients. At presentation, 58 (61.7%) were febrile, while 54 (58.1%) presented with hemodynamic instability. Majority (70.2%) received broad-spectrum antimicrobials within 2 weeks of presentation. The most common source was catheter associated infection (n = 60), 15 cases were secondary to gastrointestinal, and 9 due to a pulmonary source. Almost half, 46 (48.9%) required ICU admission. Two patients were diagnosed with endocarditis. Most isolates, 61(64.9%), were resistant to ceftazidime, 2 (2.2%) resistant to TMP/SMX and 20 (21.5%) were resistant to levofloxacin. Exposure to a quinolone in the 30 days prior to presentation did not impact fluoroquinolone resistance. Five patients were exposed to Trimethoprim/Sulfamethoxazole (TMP/SMX) in the 30 days prior to presentation, which was associated with higher rate of TMP/SMX resistance compared with those without exposure (80% vs. 98.8%, P = 0.004). Treatment options commonly included combination therapy, and TMP/SMX was a primary agent used in the majority, 59 (62.8%). All-cause in-hospital mortality was 26.6%. All-cause mortality was lower for line associated infections (16.67%) vs. other sources (44.12%) with P = 0.0038.Conclusion S. maltophilia bacteremia should be considered in hospitalized patients with recent use of broad-spectrum antibiotics. Although TMP/SMX continues to have reliable activity, use of empiric ceftazidime pending susceptibility testing should be avoided as trend toward increasing resistance is noted. We noted a drop in TMP/SMX susceptibility in those with recent reported TMP/SMX use. Disclosures All authors: No reported disclosures.
Background Fluoroquinolones (FQ) are among the most commonly prescribed antibiotics. Nephrotoxicity related to FQ use is infrequently reported and the mechanism of renal injury is incompletely elucidated. We describe clinical manifestations and outcome of patients with biopsy proven acute interstitial nephritis (AIN) associated with FQ use at our institution. Methods We conducted a retrospective review of biopsy-proven AIN attributed to FQ use at Mayo Clinic Rochester from 1993 to 2016. Cases were reviewed by a renal pathologist and attributed to FQ use by an expert nephrologist. We also reviewed and summarized all published case reports of biopsy proven AIN that were attributed to FQ use. Results We identified 24 patients with FQ-related biopsy-proven AIN. The most commonly used FQ was ciprofloxacin (71%) with median antibiotic treatment duration of 7 days (Figure 1). The median duration between starting FQ and the diagnosis of AIN was 8.5 (IQR: 17). Common clinical manifestations included fever (50%), flank pain (8%), and skin rash (21%). However, 17% of the patients were asymptomatic at the time of diagnosis (Figure 2). Majority (58%) of the patients recovered following discontinuation of antibiotics and returned to baseline renal function at a median of 20.5 (IQR: 15.5). Six patients required temporary hemodialysis and 9 patients received steroids. Conclusion Onset of FQ-related AIN can be delayed and a high index of suspicion is needed by physicians prescribing these agents. Overall outcomes are favorable with recovery to baseline renal function within 3 weeks of discontinuing the offending drug. Disclosures All authors: No reported disclosures.
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