Disseminated Mycobacterium bovis infection: Late complication of intravesical instillation of...

ID: 727Disseminated Mycobacterium bovis infection: Late complicationof intravesical instillation of Bacillus Calmette-GuérinL. Lêdo, P. Gaspar da Costa, D. Correia, S. Braz,J. Meneses Santos, R.M.M. Victorino

Department of Medicine 2, Hospital de Santa Maria, CHLN/Faculty ofMedicine Of Lisbon, Lisbon, Portugal

Immunotherapywith BCG, a live attenuated strain ofMycobacteriumbovis, is a well known and effective therapy in the treatmentof superficial bladder cancer. Although considered a relatively safetreatment, local and systemic complications may occur. Late dissemi-nated infection manifested 1 year or more after the first BCGintravesical instillation is rare, occurring in 1% of the patients. Thereare less than 50 cases of late-presentation infection described in theliterature. The authors present the case of an 80 year-old male patientwith a known diagnosis of bladder carcinoma. Two years earlier heunderwent transurethral resection of the bladder tumor followed byintravesical BCG instillation therapy. His past medical history wasremarkable for several comorbidities namely chronic kidney diseaseon hemodialysis treatment. The patient presented with asthenia,occasional low grade fever and night sweats for the last 12 months.These complaints were attributable to urinary tract infections andthe patient was started on quinolones for several times for the lastmonths. An isolated generalized seizure was reported during aprevious hospital course 1 month earlier. His bladder cancer remainedin remission. On physical examination the patient was cachectic andhad no adenopathies or meningeal signs. Laboratory investigationshowed pancytopenia. Computed tomography scan of the abdomenrevealed hepatomegaly, splenomegaly and several abdominal aortaaneurysms. The bone marrow biopsy showed noncaseating granulo-mas. A lumbar puncture was made and the cerebrospinal fluid analysisrevealed pleocytosis with a lymphocyte predominance, diminishedglucose levels and elevated protein levels and adenosine deaminase.M. bovis was isolated in the bone marrow and bronchoalveolar lavagecultures by polymerase chain reaction assay was performed con-firming the diagnosis of M. bovis disseminated infection. The patientdied 2 weeks after antituberculous therapy was started. This caseillustrates a rare late complication of intravesical BCG instillation. Wehighlight the multisystemic infection involvement (meninges, lung,bone marrow and abdominal aorta walls) and the isolation of M. bovisin two distinct locations (lung and bone marrow). We assumed thatthe insidious clinical presentation could be due to the anti-bacilaractivity of quinolones prescribed for several times prior to hospitaladmission.

doi:10.1016/j.ejim.2013.08.560

ID: 731Klebsiella pneumoniae invasive infection in animmunocompetent patientC.E. Santoa, G. Correiab, T. Marquesb, A.J. Acabadoa, J.B. Nogueiraa

aDepartment of Internal Medicine 1, Hospital de Santa Maria/CentroHospitalar de Lisboa Norte, Faculdade de Medicina de Lisboa, Lisbon,PortugalbDepartment of Infectious Diseases, Hospital de Santa Maria/CentroHospitalar de Lisboa Norte, Lisbon, Portugal

Objective: Infections with Klebsiella pneumoniae are usuallyhospital-acquired and occur primarily in patients with impaired hostdefenses. Our aim is to demonstrate that invasive K. pneumoniae

infections can also occur in immunocompetent patients. Methods:We report the case of a young healthy adult who developed aninvasive K. pneumoniae infection, with involvement of the centralnervous system (CNS). The report is given in light of the relevantliterature, which is briefly reviewed. Results: A 33-year-old healthyman had been diagnosed with perforated appendicitis complicated byperitonitis and K. pneumoniae bacteremia. He underwent abdominalsurgery and antibiotic treatment. A fewweeks later, he presentedwithfever, nuchal rigidity, a change in mental status and cerebrospinalfluid (CSF) pleocytosis; the CSF bacteriologic exam revealed K.pneumoniae. The bacterial meningitis was treated with the antibioticdetermined by the results of susceptibility testing, with ensuingclinical and analytical recovery. Meanwhile, he presented withthoracic tenderness, and imaging studies were compatible withspondylodiscitis. Endocarditis and hepatic abscess were excluded.The antibiotic treatment was prolonged for four months with clinicalsuccess. The immunological study showed no immunodeficiency.Discussion and Conclusions: K. pneumoniae is primarily a nosocomialpathogen that has been associated with urinary tract infection,pulmonary infection, bacteremia, and other infections in susceptibleindividuals. Our patient did not have any of the risk factors describedfor this agent, yet he developed a disseminated/metastatic infection.Certain virulent strains are prone to cause a destructive abscesssyndrome with possible metastatic infection in an immunocompetenthost. This case adds to existing reports on this syndrome, andreinforces the importance of keeping in mind the hypothesis of K.pneumoniae as a causative agent even in the setting of an invasive/metastatic infection, with CNS involvement, in an immunocompetentpatient.

doi:10.1016/j.ejim.2013.08.561

ID: 742The secret behind the stroke: A case reportS. Rodrigues, M. Manso, S. Rodeia, R. Domingos, F. Silva, A.M. Silva

Serviço de Medicina II, Hospital Egas Moniz, CHLO, Lisboa, Portugal

Malignant otitis externa (MOE) is a life-threatening infection ofthe skull base, occurring mostly in diabetic patients. Its presentationis not always typical, varying from local symptoms to severeneurologic complications. Prognosis is highly variable, dependingon early recognition and aggressive therapy. The authors describe acase of a 81-year-old female with poorly controlled type 2 diabetesadmitted with left hemiparesis and left homonym hemianopsia.Concurrently, she complained of severe occipital headache, withirradiation to the cervical right region, in the previous month. Onadmission, a brain computed tomography (CT) revealed no secureischemic lesion (although bilateral lacunar infarctions were present)and a mass in the right pharyngeal mucosal space, with tissueinflammation and necrosis. A previous history of chronic otitis mediaand a mild elevation of inflammatory markers were then valued andthe requested magnetic resonance lead to the diagnosis of MOE,complicated by extensive skull base osteomyelitis with cranial nerveforamina involvement and internal carotid vasculitis, with significantstenosis of the arterial lumen. This inflammatory condition waspresumed to be the cause of the stroke she presented with. In allcollected samples, Pseudomonas aeruginosa was isolated and doubletargeted antibiotic treatment was started, in association withhyperbaric oxygen therapy. Six week CT control showed signs ofamelioration of soft tissue infection and bony remineralisation.Unfortunately, the patient died shortly after of unknown cause.

Abstracts e219