[A rare case of sepsis from Citrobacter koseri in adults]

We describe the case of a 53-year-old man, recently diagnosed with decompensated type II diabetes mellitus, admitted to our Department for fever, asthenia, and detection of multiple lung abscesses and pulmonary embolism at chest tomography.His clinical history revealed just a recent orthopedic surgery of osteosynthesis on the left wrist with normal clinical and instrumental post-surgical evolution. Empirical antibiotic therapy with piperacillin/tazobactam and clindamycin was initiated. During hospital stay, swelling and functional impotence in the right knee occurred. They were investigated by arthrocentesis and magnetic resonance, and diagnosed as septic arthritis.Blood culture performed at admission tested positive for Citrobacter koseri on several samples where meropenem was added according to antibiogram. On the other hand, the cultures of bronchoaspirate, pulmonary fine needle aspiration, and arthrocentesis were negative.Antibiotic therapy was administered up to two weeks after discharge and radiological and physical features progressively improved.

Placenta Accreta: Management by Peridural Anesthesia

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Iatrogenic Hypoglycemia Induced by Valproic Acid in an Adult Patient

Literature on antiepileptic induced iatrogenic hypoglycemia is scanty. Due to its broad spectrum of activity and mechanisms of action, valproic acid (VPA), a fatty acid, is the most widely prescribed epilepsy treatment worldwide.Herein, we describe an adult epileptic patient, where persistent, otherwise unexplained hypoglycemia, was most likely induced by VPA, as suggested by the VPA time course and glucose blood levels. Indeed, no further hypoglycemic episodes occurred after VPA discontinuation and the diagnostic work-up ruled out other possible causes of hypoglycemia.This case supports the hypothesis that VPA may induce hypoglycemia, due to still not well-defined metabolic mechanisms of action. Moreover, it emphasizes the fact that an iatrogenic pathogenesis should be considered if an apparently unexplained hypoglycemia occurs in a patient on chronic therapy with antiepileptics, even at a therapeutical dosage.

Familial Gullo’s Syndrome: a clinical case report

This case report describes a male patient born in 1953 presenting an occasional increase in serum amylase and lipase forty years ago. The monitoring of enzymes was accompanied by radiological investigations, which did not reveal pancreatic pathology. In his family, including 10 siblings, half were carriers of this isolated anomaly; multiple cysts in pancreas, kidneys, and liver were present in some family members, in addition to a pancreatic neoplasia in a sister who did not carry the enzymatic abnormality. Our patient developed colon adenocarcinoma at the age of 67.Here we examine the characteristics of non-pathological chronic pancreatic hyperenzymemia defined as such by the main Italian pioneer Professor Gullo.

Risk of Colorectal Cancer in Inflammatory Bowel Disease: Prevention and Monitoring Strategies According With Risk Factors

Colorectal cancer (CRC) is slightly increased in inflammatory bowel disease (IBD) patients, with roughly a 2.5-fold increase compared to the general population. Clinical features associated to CRC risks are extent and severity of colonic involvement, disease duration, concomitant primary sclerosing cholangitis (PSC) and/or familial history of CRC in first-degree relatives. Colonic Crohn’s disease (CD) and ulcerative colitis (UC) share similar risks when similar colonic extent is affected. Risk stratification affects outcomes and surveillance programs.Newer endoscopic techniques substantially ameliorated diagnostic performance of endoscopy, and nowadays the standard for CRC surveillance in IBD patients is high-definition endoscopy, with dye-spray or virtual colonoscopy, oriented at targeted (+ random) colonic biopsies.Visible dysplastic lesions should be considered for endoscopic resection, while invisible dysplasia is still a mandatory proctocolectomy indication.Newer endoscopic interventional techniques (endoscopic mucosa resection, EMR, and endoscopic submucosal dissection, ESD) are appropriate therapeutic techniques to be delivered, but long-term risks of cancer should be balanced towards proctocolectomy.

Treatment With Efmoroctocog Alfa (Elocta®) in Hemophilia: A Case Series

Hemophilia A is a rare X-linked disease that occurs as a result of a defect in the FVIII-encoding gene. The reduction or absence of plasma FVIII compromises the coagulation cascade, resulting in frequent bleeds, especially in joints or soft tissues. Currently, replacement therapy with coagulation factor concentrates is the gold standard for the treatment of FVIII deficiency.Herein, we report a case series of five hemophilia A patients treated with an extended half-life recombinant human coagulation factor, FVIII-Fc fusion protein (efmoroctocog alfa). The prophylactic regimen for each patient was individualized based on their pharmacokinetic profile.Compared to previous prophylactic treatments, most patients received a reduced weekly dose of concentrate, all underwent a reduced frequency of administration, the annualized bleeding rates (ABR) and hemophilia joint health scores (HJHS) were stable or improved. The half-life of efmoroctocog alfa and the 72-hour trough levels were higher than those observed in the A-LONG Phase III trial.In conclusion, all patients reported clinical improvements and general subjective wellbeing in the absence of significant safety concerns after switching to efmoroctocog alfa.

Cerebral Embolism Beyond Atrial Fibrillation: Interatrial Block

This paper is devoted to conditions that imply a risk for cerebral embolism beyond atrial fibrillation (AF). We focus on advanced interatrial block (IAB) and its relationship with stroke in elderly patients with no documented arrhythmias. Advanced IAB is manifested in the surface electrocardiogram (ECG) as a P-wave duration >120 ms plus biphasic morphology (positive and negative deflection) in leads II, III, and aVF. Several data suggest that AF is not necessarily the leading cause of stroke, but rather a risk factor. In fact, a high stroke risk has been described even in the absence of AF in patients with high CHA2DS2VASc-score (Congestive Heart failure, hypertension, Age ≥75 years [doubled], Diabetes, Stroke [doubled], Vascular disease, Age 65-74 years, Sex category [female sex]). Moreover, excessive atrial ectopy and short atrial runs also increase stroke risk. Some of the previously mentioned stroke risk factors in patients without documented arrhythmias might be combined to determine thrombotic risk. That risk is particularly high in elderly patients with advanced IAB, structural heart disease, CHA2DS2-VASc score ≥3, and frequent ambient atrial arrhythmias. Systematic screening for advanced IAB in elderly patients can be performed with a simple surface ECG. Advanced IAB is a risk marker of stroke.