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ID: 727 Disseminated Mycobacterium bovis infection: Late complication of intravesical instillation of Bacillus Calmette-Guérin L. 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 of Medicine Of Lisbon, Lisbon, Portugal Immunotherapy with BCG, a live attenuated strain of Mycobacterium bovis, is a well known and effective therapy in the treatment of supercial bladder cancer. Although considered a relatively safe treatment, local and systemic complications may occur. Late dissemi- nated infection manifested 1 year or more after the rst BCG intravesical instillation is rare, occurring in 1% of the patients. There are less than 50 cases of late-presentation infection described in the literature. The authors present the case of an 80 year-old male patient with a known diagnosis of bladder carcinoma. Two years earlier he underwent transurethral resection of the bladder tumor followed by intravesical BCG instillation therapy. His past medical history was remarkable for several comorbidities namely chronic kidney disease on 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 and the patient was started on quinolones for several times for the last months. An isolated generalized seizure was reported during a previous hospital course 1 month earlier. His bladder cancer remained in remission. On physical examination the patient was cachectic and had no adenopathies or meningeal signs. Laboratory investigation showed pancytopenia. Computed tomography scan of the abdomen revealed hepatomegaly, splenomegaly and several abdominal aorta aneurysms. The bone marrow biopsy showed noncaseating granulo- mas. A lumbar puncture was made and the cerebrospinal uid analysis revealed pleocytosis with a lymphocyte predominance, diminished glucose levels and elevated protein levels and adenosine deaminase. M. bovis was isolated in the bone marrow and bronchoalveolar lavage cultures by polymerase chain reaction assay was performed con- rming the diagnosis of M. bovis disseminated infection. The patient died 2 weeks after antituberculous therapy was started. This case illustrates a rare late complication of intravesical BCG instillation. We highlight the multisystemic infection involvement (meninges, lung, bone marrow and abdominal aorta walls) and the isolation of M. bovis in two distinct locations (lung and bone marrow). We assumed that the insidious clinical presentation could be due to the anti-bacilar activity of quinolones prescribed for several times prior to hospital admission. doi:10.1016/j.ejim.2013.08.560 ID: 731 Klebsiella pneumoniae invasive infection in an immunocompetent patient C.E. Santo a , G. Correia b , T. Marques b , A.J. Acabado a , J.B. Nogueira a a Department of Internal Medicine 1, Hospital de Santa Maria/Centro Hospitalar de Lisboa Norte, Faculdade de Medicina de Lisboa, Lisbon, Portugal b Department of Infectious Diseases, Hospital de Santa Maria/Centro Hospitalar de Lisboa Norte, Lisbon, Portugal Objective: Infections with Klebsiella pneumoniae are usually hospital-acquired and occur primarily in patients with impaired host defenses. 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 an invasive K. pneumoniae infection, with involvement of the central nervous system (CNS). The report is given in light of the relevant literature, which is briey reviewed. Results: A 33-year-old healthy man had been diagnosed with perforated appendicitis complicated by peritonitis and K. pneumoniae bacteremia. He underwent abdominal surgery and antibiotic treatment. A few weeks later, he presented with fever, nuchal rigidity, a change in mental status and cerebrospinal uid (CSF) pleocytosis; the CSF bacteriologic exam revealed K. pneumoniae. The bacterial meningitis was treated with the antibiotic determined by the results of susceptibility testing, with ensuing clinical and analytical recovery. Meanwhile, he presented with thoracic tenderness, and imaging studies were compatible with spondylodiscitis. Endocarditis and hepatic abscess were excluded. The antibiotic treatment was prolonged for four months with clinical success. The immunological study showed no immunodeciency. Discussion and Conclusions: K. pneumoniae is primarily a nosocomial pathogen that has been associated with urinary tract infection, pulmonary infection, bacteremia, and other infections in susceptible individuals. Our patient did not have any of the risk factors described for this agent, yet he developed a disseminated/metastatic infection. Certain virulent strains are prone to cause a destructive abscess syndrome with possible metastatic infection in an immunocompetent host. This case adds to existing reports on this syndrome, and reinforces 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 immunocompetent patient. doi:10.1016/j.ejim.2013.08.561 ID: 742 The secret behind the stroke: A case report S. 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 of the skull base, occurring mostly in diabetic patients. Its presentation is not always typical, varying from local symptoms to severe neurologic complications. Prognosis is highly variable, depending on early recognition and aggressive therapy. The authors describe a case of a 81-year-old female with poorly controlled type 2 diabetes admitted with left hemiparesis and left homonym hemianopsia. Concurrently, she complained of severe occipital headache, with irradiation to the cervical right region, in the previous month. On admission, a brain computed tomography (CT) revealed no secure ischemic lesion (although bilateral lacunar infarctions were present) and a mass in the right pharyngeal mucosal space, with tissue inammation and necrosis. A previous history of chronic otitis media and a mild elevation of inammatory markers were then valued and the requested magnetic resonance lead to the diagnosis of MOE, complicated by extensive skull base osteomyelitis with cranial nerve foramina involvement and internal carotid vasculitis, with signicant stenosis of the arterial lumen. This inammatory condition was presumed to be the cause of the stroke she presented with. In all collected samples, Pseudomonas aeruginosa was isolated and double targeted antibiotic treatment was started, in association with hyperbaric oxygen therapy. Six week CT control showed signs of amelioration of soft tissue infection and bony remineralisation. Unfortunately, the patient died shortly after of unknown cause. Abstracts e219

Disseminated Mycobacterium bovis infection: Late complication of intravesical instillation of Bacillus Calmette-Guérin

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Page 1: Disseminated Mycobacterium bovis infection: Late complication of intravesical instillation of Bacillus Calmette-Guérin

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