Medicine
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Severe community-acquired pneumonia (CAP) requiring admission to an intensive care unit (ICU) has been inadequately studied. We compared characteristics and outcomes of patients with CAP who were admitted to the ICU with those of patients managed on the ward. Of the 3675 patients hospitalized with CAP, 374 (10%) were admitted to the ICU. ⋯ The following factors were predictive of ICU admission on multivariable analysis: younger age, smoker, limitation of functional status, absence of cough or pleurisy, presence of chronic obstructive pulmonary disease, substance abuse, elevated serum creatinine, abnormal serum glucose concentration, and a respiratory rate of <16 or >24 breaths per minute. Patients with low Pneumonia Severity Index scores and low CURB-65 scores were admitted to the ICU based on clinical judgment that appeared to supersede objective scoring. Severe CAP requiring admission to the ICU is common, and the decision about which patients to admit often requires clinical judgment that in many cases appears at odds with various validated pneumonia severity scoring systems.
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Streptococcus pneumoniae infections can cause serious systemic disease in patients following hematopoietic stem cell transplantation (HSCT), and the response to pneumococcal vaccine is inadequate in most HSCT recipients. We evaluated the clinical spectrum of pneumococcal disease and vaccine-breakthrough infections in HSCT recipients at our cancer center in a retrospective analysis of all consecutive episodes of S. pneumoniae infection from 1989 through 2005. During the study period, 7888 patients underwent HSCT at our center; we identified 47 HSCT recipients with 54 S. pneumoniae infections. ⋯ All 5 (11%) patients who developed vaccine-breakthrough S. pneumoniae infection (546 +/- 732 d following vaccination) had pneumonia, and in 4 patients concurrent bacteremia also occurred. A serious S. pneumoniae infection in HSCT recipients occurred more commonly in patients with lymphoma and patients receiving high-dose systemic corticosteroid therapy. It is noteworthy that there were no cases of extrapulmonary organ infection in HSCT recipients who presented with S. pneumoniae infection at our institution.
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Susac syndrome is characterized by the clinical triad of encephalopathy, hearing loss, and retinal artery branch occlusions, mostly in young women. To our knowledge, long-term outcome and impact of pregnancy have not been specifically addressed. We report a series of 9 patients (7 female, 2 male) followed at the same institution, with special emphasis on clinical outcome including pregnancy and long-term sequelae. ⋯ In conclusion, at the end of follow-up, most patients had returned to work and none had severe impairment. Pregnancy may affect the course of Susac syndrome, with relapse of encephalopathy postpartum. Our main finding was that the course of Susac syndrome is not self-limited as previously thought, since isolated retinal arteriolar involvement may occur as a very late manifestation.
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Differential diagnosis of fever in travelers returning from the tropics is extremely diverse. Apart from the travel destination, other diagnostic predictors of tropical infections are poorly documented in returning travelers. From April 2000 to December 2005, we prospectively enrolled all patients presenting at our referral centers with fever within 1 year after visiting a tropical or subtropical area. ⋯ Malaria (mainly Plasmodium falciparum) was strongly predicted by the following features: enlarged spleen, thrombocytopenia (platelet count <150 x 10(3)/microL), fever without localizing symptoms, and hyperbilirubinemia (total bilirubin level >or=1.3 mg/dL). When malaria had been ruled out, main predictors were skin rash and skin ulcer for rickettsial infection (mainly African tick bite fever); skin rash, thrombocytopenia, and leukopenia (leukocyte count <4 x 10(3)/microL) for dengue; eosinophil count >or=0.5 x 10(3)/microL for acute schistosomiasis; and enlarged spleen and elevated alanine aminotransferase level (>or=70 IU/L) for enteric fever. The initial clinical and laboratory assessment can help in selecting appropriate investigations and empiric treatments for patients with imported fever.
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Risk factors for complications of catheter-related Staphylococcus aureus bacteremia (CRSAB) have been studied in the general patient population but have not been well defined in cancer patients. We investigated potential risk factors for intravascular and extravascular complications in these patients. We retrospectively reviewed the records of patients with CRSAB hospitalized at our institution between January 2001 and December 2004. ⋯ Renal failure is a risk factor for CRSAB complications in patients with cancer. Patients with solid tumors and CRSAB tend to develop intravascular complications, while patients with hematologic malignancies are prone to develop extravascular complications. Hence consideration should be given to extending the duration of therapy beyond 2 weeks.