162 32nd World Congress of Internal Medicine (October 24-28, 2014) WCIM 2014
PS 0446 Infectious Disease
Fever of Unknown Cause Which is the Cause of Intesti- nal Tuberculosis
Tugrul Burak GENC1, Yildiz OKUTURLAR1, Özlem HARMANKAYA1, Suut GÖKTÜRK2, Bülent DURDU3, Samet SAYILAN1, Selcuk SEZIKLI1, Meral MERT1, A.Baki KUMBASAR1 Internal Medicine, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Turkey1, Gastroenterology, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Turkey2, Infectious Disease, Bakirköy Dr. Sadi Konuk Research and Training Hospital, Turkey3
Background: In developing countries, tuberculosis (tbc) incidence is reduced; but immunocompromised patients still remain at high risk for the disease. Malignancy and Crohn’s disease should be considered in the differential diagnosis of gastrointestinal (GIS) tbc in immunocompromised patients. We present here the clinical course of a patient with fever of unknown origin and rectal bleeding.
Methods: A 31-year-old male cachectic patient was admitted to hospital with ab- dominal pain, fever and diarrhea. The history of the patient revealed systemic lupus erythematosus, lupus nephritis and left middle cerebral artery infarction. Right hemiparesis was present. He was on warfarin 5mg/day, cilazapril 2,5mg/day, meth- ylprednisolone 4mg/day, mycophenolate mofetil 2g/day, hydroxychloroquine 200mg/
day, levodopa+benserazide 375mg/day, levetiracetam 1 g/day. Creatinine was 2,79mg/dL, and C-reactive protein was 10 mg/dL. No pneumonic infi ltration was shown. Blood, urine and faeces cultures, Chlamydia IgM, mycoplasma IgM, toxoplasma IgM, EBV IgM, CMV IgM and PPD test were negative. Transesophageal echocardiography excluded infective endocarditis. Empiric antibiotic treatment with ceftriaxone, piperacillin-tazobactam and moxifl oxacin, and antifungal fl uconazole was started. On the 15th day hematochezia occured. Colonoscopy revealed three different massive lesions straightening the lumen in caecum, hepatic fl exure of colon and transverse colon (Figure-1).
Results: Pathologic examination demonstrated granulomatous lesion. Considering the positive results of Tbc-PCR treatment, the patient was diagnosed as GIS tbc and iso- niazid, rifampicin, pyrazinamide and ethambutol were started.
Conclusions: The ileocecal region is the most frequent localization of intestinal tbc.
Colonic tbc is often localized in proximal colon and caecum, and usually associated with ileal tbc. It is rarely seen in transverse colon. Our patient is a rare case of gastro- intestinal tbc presenting without pneumonic infi ltration and with an unusual localiza- tion in colon.
PS 0448 Infectious Disease
A Case of Scrub Typhus with Cerebral Infarction in Spring
Min Young BAEK1, Joon Hwan KIM1, Song Mi MOON1, Yoon Soo PARK1, Yong Kyun CHO1
Gachon University Gil Hospital, Korea1
Scrub typhus, which almost patients getting in autumn, is an acute febrile illness caused by Orientia tsutsugamushi, and characterized by an eschar, lymphadenopathy, multiorgan involvement. The central nervous system is the most crucial target in scrub typhus as in other rickettial disease. A 58-year-old woman was admitted to hospital because of disturbed consciousness in May this year. The patient had a fever, headache and neck stiffness for four days before admission. She had aphagia and weakness of lower extremities, and then we found an 0.5cm x 0.5cm sized eschar on left posterior thigh. Serum indirect immunofl uorescent antibody against O.tsutsugamushi is 1:2560.
The magnetic resonance image of the brain showed high signal intensity on diffusion weighted image at left corona radiate-basal ganglia. We diagnosed her illness as scrub typhus complicated by cerebral infarction. After treating her with doxycycline and an anticonvulsant, aphagia and lower extremities’ weakness were improved to some extent. This case suggests that O. tsutsugamushi should be considered as one of the causes of fever with neurologic symptoms even in the springtime in endemic areas.
PS 0449 Infectious Disease
Analysis of Recombinant Envelope (E) Protein Dengue Virus Serotype -1,-3,-4 Expressed by Baculovirus Sys- tem
Purwati PURWATI1 Roche Indonesia, Indonesia1
Dengue virus have four serotype that still in currently as causing a public health problem in Indonesia. This disease have no more vaccine already to be used preven- tion, however some model of vaccine have been under developed. Three isolate of Dengue virus (DENV-1, 3, 4) were extracted and cloned envelop (E) protein gene using E.coli and then subcloned by baculovirus and cotransfected into sf9 cell. Recombinant of DNA fragment envelop (E) gene that codes for E protein in one open reading frame were inserted in the site Smal and Sacl of plasmid component structural gene con- tained polyhedrin. Sequence of coded recombinant E protein gene have been showed relative stable with 97% - 98% homologous, and were founded changing of amino acids in some region. The antigenecity properties to bind antibodies have showed highest reactivity with polyclonal human sera infected dengue virus than immunized mice, but to bind with monoclonal antibodies IgG1a and IgG2b high reactivity than other isotopes of IgM, IgG, and Ig1b. Recombinant E protein can induce cellular im- mune response by immunized mice, and were showed by lymphocytes secreted IL-3.
This study have indicates that recombinant E protein expressed in baculovirus system can induce humoral and cellular immune response.
PS 0450 Infectious Disease
Streptococcus Anginosus Group Infections: 2 Case Reports
Shalini SRI KUMARAN1, Kavitha GARUNA MURTHEE1 Singapore General Hospital, Singapore1
The Streptococcus anginosus group (SAG) consists of three different species: Strep- tococcus anginosus, Streptococcus intermedius, and Streptococcus constellatus. SAG species are common human fl ora from the oral cavity and gastrointestinal tract but with a propensity to cause invasive pyogenic abscesses at sites such as brain, hepatic, splenic and even infective endocarditis albeit less commonly. We report two cases with SAG infections encountered in a week that caused infections at different sites.
An 80-year-old man with a bioprostethic aortic valve presented with fever, chills, and constitutional symptoms. This was following a recent discharge from hospital for a stroke and treated SAG bactaraemia from unknown source. Clinically he was febrile and tachycardic. Laboratory fi ndings revealed leukocytosis, and blood cultures grew SAG again. An initial transthoracic echocardiography was reported as having no valvular vegetations but a transesophageal echocardiography showed a large fi lamen- tous mobile vegetation. He was continued on intravenous Ceftriaxone for 6 weeks and made good recovery. The second case was of a 70-year-old man with a malignant pancreatic tumour and a history of cholangitis with stenting done. He presented with abdominal pain. Clinically, he was jaundiced, febrile, tachycardic and hypotensive.
Blood investigations revealed leukocytosis and the blood cultures grew polymicrobial bacteria: Escherichia Coli, Proteus Vulgaris and SAG. The initial impression was pol- ymicrobial infection from a blocked stent. However despite changing the stent, an US abdomen revealed a large hepatic mass representing an abscess and blood cultures grew SAG again. He was continued on intravenous Cefepime for 4 weeks and a repeat US showed a decrement in the mass size and blood cultures were cleared as well. The patient however developed complications from his malignancy and passed on soon after. This report illustrates the various different clinical manifestations and implica- tions of the SAG bacteria.
