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Case 374

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A 38 years-old male patient with hypertension, diabetes and undergoing renal replacement therapy with hemodialysis through femoral catheterization is admitted with arthralgia, pain and swelling in the right thigh. Physical examination of the patient reveals a poor general status, conscious, feverish, dyspneic and with chills. The patient has an important pre-sternal bulging and cervical and inguinal lymphadenopathy. The medical team orders blood-cultures and computed tomography of the thorax (Images 1 to 4).

Considering the clinical history and the imaging exams presented, what is the most likely diagnosis and the most appropriate initial therapeutic approach?

a) Catheter-related bloodstream infections. Hospitalization and IV antibiotic therapy.

25%

b) Hodgkin’s Lymphoma. Hospitalization, neoplasm staging and chemotherapy.

25%

c) Disseminated tuberculosis with lung and ganglionar involvement. RIPE drug regimen for 6 months.

25%

d) Sternal chondrosarcoma. Hospitalization and surgical exeresis of the tumor.

25%
   

Image analysis

 

Image 1: Computed tomography of the thorax, axial view, T3 level, mediastinum window, after the intravenous infusion of iodinated contrast media. Pre-sternal mass with defined limits, slightly lobulated outlines with septa (red arrows) ), with homogenous, low density content  (12 UH to 21 UH) and with tiny gaseous accumulations of permeation (blue arrow), showing impregnation of contrast media only in its parietal portion.

 

 

Image 2: Computed tomography of the thorax, axial view, T5 level, mediastinum window, after the intravenous infusion of iodinated contrast media. Pre-sternal and retrosternal mass (red arrows) associated with osteolytic lesions in the left lateral edge of sternum (yellow arrow). Presence of gaseous accumulations between the right muscular (white arrows).

 

 

Image 3 : Computed tomography of the thorax, axial view, T6 level, lung window. Opacity in the left upper pulmonary lobe with excavations, compatible with abscess (red arrow). Perifissural  alveolar consolidation on the posterior border of left upper lobe with air bronchograms, compatible with the pneumonic process (yellow arrow). Bilateral pleural effusion (green arrows).

 

 

Image 4 : Computed tomography of the thorax, after the intravenous infusion of iodinated contrast media, right paramedian sagittal reconstruction. Presence of collection with low density content on pre-sternal and cervical regions (red-dotted areas), compatible with abscesses.

 

 

Image 5: Moment of surgical drainage of pre-sternal collection.

 

 

Image 6:  Moment of suction of purulent content of pre-sternal collection for analysis.

Highlights

   -   The catheter-related bloodstream infections are a severe and lethal complications in patients with central venous catheterization, especially in those undergoing renal replacement therapy by hemodialisis;

   -  Clinical manifestations range from malaise and nausea to sepsis;

   -  The diagnosis includes at least 2 positive blood cultures samples and a compatible infectious clinic in patients using a catheter;

   -  The infected catheter must always be removed after isolation of S.aureus, Pseudomonas spp. or Candida spp. Routine catheter culture is not indicated;

   -  ATB should be started empirically and reviewed later after the results of blood culture samples and antibiogram.

References

   -  Gahlot, R., Nigam, C., Kumar, V., Yadav, G., & Anupurba, S. (2014). Catheter-related bloodstream infections. International journal of critical illness and injury science, 4(2), 162–167. doi:10.4103/2229-5151.134184

   -  Mermel, L. A., Allon, M., Bouza, E., Craven, D. E., Flynn, P., O'Grady, N. P., … Warren, D. K. (2009). Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 49(1), 1–45. Available from doi:10.1086/599376

   -  Critérios Diagnósticos de Infecções Relacionadas à Assistência à Saúde. (2017). Agência Nacional de Vigilância Sanitária (ANVISA). http://www.anvisa.gov.br/servicosaude/controle/rede_rm/cursos/rm_controle/opas_web/modulo5/pre_corrente.htm

Author

Raphael Dias, 5th year medical student at Universidade Federal de Minas Gerais.

E-mail: diasraphaelf[at]gmail.com

Supervisors

Júlia Fonseca de Morais Caporali, Professora Assistente do Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Minas Gerais.

E-mail: julietcaporali[arroba]hotmail.com

 

Cécil Bruno Buldrini Filogônio, Professor do Departamento de Anatomia e Imagem da Faculdade de Medicina da Universidade Federal de Minas Gerais.

E-mail: cecilbruno[arroba]gmail.com.

Reviewers

Mirella Diniz, Gabriella Shiomatsu, Mateus Nardelli, Lara Hemerly, Felipe Eduardo Fagundes Lopes, Prof. José Nelson Mendes Vieira, Profa. Vivane Santuari Parisotto Marino.

Translated by

Raphael Dias, 5th year medical student at Universidade Federal de Minas Gerais.

E-mail: diasraphaelf[at]gmail.com

Test question

a)

25%

b)

25%

c)

25%

d)

25%

e)

25%
   

Commentics

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