Article, Emergency Medicine

Timely identification of bacterial pathogens may reduce inappropriate antibiotic prescription

i An update to this article is included at the end

American Journal of Emergency Medicine (2010) 28, 519-533

Correspondence

Adult onset of Still disease: a difficult diagnosis to make in the ED

To the Editor,

Adult onset of Still disease is a fascinating disorder of unclear etiology that mimics many conditions ranging from autoimmune diseases, malignancy, and infection [1,2]. The disease is a diagnosis of exclusion; and making such a diagnosis solely on at the basis of bloods tests, a chest x-ray, and an echocardiogram is very brave. Adult onset of Still disease is a difficult diagnosis to make in the emergency department; and as mentioned in the exclusion criteria provided by the authors, the main diagnosis to exclude are infections and malignancy especially of hematologic origin [3]. Ferritin is of little diagnostic value because it would be elevated in many acute phase responses. In previous cases, we had also performed an extensive infectious disease screen, a TNF receptor associated periodic syndrome or TRAPS screen and immunoglobulin D to exclude the possibility of periodic fever syndrome, and extensive full body imaging and endoscopies. A bone marrow aspirate was also performed to exclude hemophagocytosis. This case certainly high- lights the multisystem nature of adult onset of Still disease and therefore the difficulty in making such a diagnosis. It also highlights the importance to think outside the box; and because of its rarity, the therapeutic decisions are based on various case reports of the disease, with organ involvement and the severity dictating intensity of treatment. Novel markers of disease (interleukin-18, glycosylated ferritin) are being investigated and may improve diagnosis and monitoring of the disease in the future [4,5].

Carlos Lojo Rial BMBS Emergency Medicine Department King’s College Hospital

London SE5 9RS, UK E-mail address: [email protected]

doi:10.1016/j.ajem.2010.01.017

References

  1. Mehrpoor G, Owlia MB, et al. Adult-onset Still’s disease: a report of 28 cases and review of the literature. Mod Rheumatol 2008;18(5):480-5.
  2. Efthimiou P, Paik PK, et al. Diagnosis and management of adult onset Still’s disease. Ann Rheum Dis 2006;65(5):564-72.
  3. Jimenez D, Allegretti P, Kallal K. Adult Still disease: worsening Inflammatory changes in a 26 year old woman. American Journal of Emergency Medicine 2010;28(1):114.
  4. Wang Z, Wang Y, et al. Early diagnostic value of low percentage of glycosylated ferritin in secondary hemophagocytic lymphohistiocytosis. Int J Hematol 2009;90(4):501-5.
  5. Fardet L, Coppo P, et al. Low glycosylated ferritin, a good marker for the diagnosis of Hemophagocytic Syndrome. Arthritis Rheum 2008;58 (5):1521-7.

Timely identification of bacterial pathogens may reduce inappropriate antibiotic prescription

To the Editor,

Given the fact that Streptococcus pneumoniae is the commonest bacterial cause of community-acquired pneumo- nia (CAP) [1], the urine antigen test (Binax) that can generate results in 15 minutes [2,3] might prove useful in identifying the underlying cause in most patients with CAP, well within the recommended 4-hour therapeutic time window, thereby reducing the likelihood of inappropriate empiric prescription of antibiotics [4], with its attendant risk of generating antibiotic resistance [5]. In 2 recent studies, the Binax urine antigen immunochromatographic test was positive in 85% to 88% of cases of bacteremic pneumococcal pneumonia [2,3]. Specificity for pneumococcal pneumonia amounted to 98% (95% confidence interval [CI], 92%-100%), using either blood culture or sputum positivity (Gram stain or culture) as the criterion standard [2], and 96% (95% CI, 86.5%-99.5%) using Blood culture positivity as the criterion standard [3]. Systematic review of 25 published studies of Binax immunochromatographic test use (with blood and/or sputum positivity as the criterion standard) yielded pooled sensitivity amounting to 74% (95% CI, 70%-90%) and pooled

specificity amounting to 94% (95% CI, 91%-100%) [2].

0735-6757/$ – see front matter (C) 2010

520 Correspondence

Urine antigen tests can also be used in suspected legionellosis, as shown by a systematic review of 30 published studies that yielded pooled sensitivity amounting to 74% (95% CI, 68%-81%) and pooled specificity of 99.1% (95% CI, 98.4%-99.7%) [6]. Accordingly, this technology could be a useful addition to the armamentarium for “resurrection of the basic principles of infectious disease, which are to identify the microbial etiology of the infection and to use narrow, targeted antimicrobial therapy” [7]. Within the constraints imposed by the 4-hour therapeutic time window, these principles cannot be resurrected by diagnostic reliance on blood cultures, hence the documen- tation of limited usefulness of this modality in the routine management of patients admitted to hospital with uncom- plicated CAP [8,9]. Even so, given the fact that in pneumococcal meningitis, it takes approximately 4.3 hours for the first dose of antibiotics to sterilize the cerebrospinal fluid [10], it may well be that, in the context of bacteremic pneumococcal pneumonia, culture of the culprit organism from the blood stream might also be possible some hours after initiation of antibiotic therapy.

Oscar M.P. Jolobe MD, DPhil

Manchester Medical Society C/o John Rylands University Library Oxford Road, Manchester M13 9PP, USA E-mail address: [email protected]

doi:10.1016/j.ajem.2010.01.022

References

  1. Van der Poll T, Opal SM. Pathogenesis, treatment, and prevention of pneumococcal pneumonia. Lancet 2009;374:1543-56.
  2. Boulware DR, Daley CL, Merrifield C, Hopewell PC, Janoff EN. Rapid diagnosis of pneumococcal pneumonia among HIV-infected adults with urine antigen detection. J Infect Dis 2007;43:3221-6.
  3. Smith MD, Sheppard CL, Hogan A, et al. Diagnosis of Streptococcus pneumoniae infections in adults with bacteremia and community- acquired pneumonia: clinical comparison of pneumococcal PCR and urinary antigen detection. J Clin Microbiol 2009;47:1046-9.
  4. Fee C, Metlay J, Camargo CA, Maselli JH, Gonzales R. ED antibiotic use for acute respiratory illnesses since pneumonia performance inception. Am J Emerg Med 2010;28:23-31.
  5. File TM. The science of selecting antimicrobials for community acquired pneumonia (CAP). J Manag Care Pharm 2009;15(2 Suppl):S5-S11.
  6. Shimada T, Noguchi Y, Jackson JL, et al. Systematic review and metaanalysis. Urinary antigen tests for Legionellosis. CHEST 2009;136:1576-85.
  7. Yu VL, Stout JE. Rapid diagnostic testing for community-acquired pneumonia. CHEST 2009;136:1618-21.
  8. Campbell SG, Marrie TJ, Anstey R, Dickson G, Ackroyd-Stolarz S, for the capital Study Investigators. The contribution of blood culture to the clinical management of adult patients admitted to the hospital with community-acquired pneumonia. A prospective observational study. CHEST 2003;123:1142-50.
  9. Luna CM. Blood cultures in community-acquired pneumonia. Are we ready to quit. CHEST 2003;123:977-8.
  10. Kanegaye JT, Soliemanzadeh P, Bradley S. Lumbar puncture in pediatric Bacterial meningitis: defining the time interval for recovery of

cerebrospinal fluid pathogens after parenteral antibiotic pre-treatment. Pediatrics 2001;108:1169-74.

Letter to the editor

To the Editor,

In an article published in the October issue of your journal, Chang et al [1] questioned the validity of this notion that presence of new–or presumed new–left bundle- branch block (LBBB) predicts the presence of acute myocardial infarction (AMI). In this cohort study, the researchers follow a large group of adult patients with either chest pain or other angina equivalents (if interpreted by the treating physician as such) who had an electrocardiogram. They find that the prevalence of AMI among the small subgroup of patients (0.6%) who manifested LBBB on their electrocardiograms and in whom the LBBB is not known to be old (7.3%) was not significantly different from those with known Old LBBB (5.2%) or those without LBBB (6.1%). The investigators should be congratulated for their initiative and courage to challenge a widely used recommendation that has well found its way into well-known guidelines. They have also adopted an appropriate method for their study and conducted an acceptable follow-up.

Although the findings of this study are very interesting, the authors’ suggestion that “New or Presumed new LBBB provides limited diagnostic value in identifying patients with AMI” should be accepted more cautiously. There are some major concerns that need to be addressed before such an important conclusion can be made. Although the authors point to one of these limitations, I think it has not received the attention it deserved.

The most important statistic that I am interested in is the number of patients in the “no LBBB” group who manifested ST segment elevation. I found no clue suggesting that these patients have been separated from the others with no LBBB. If this is the case, I will not be surprised to know that the proportion of patients with AMI in the 2 groups is similar. I would also like to know what proportion of the patients with old LBBB had the Sgarbossa criteria for AMI in the presence of LBBB. Last but not least, we cannot make a generalization until we know the proportion of patients with new and those with presumed new LBBB, a point that has also been put forth by the authors.

Another consequential information that cannot be found in the article is the completeness of the follow-up. Although 3% loss to follow-up is an acceptable–and in fact very desirable–rate, the authors fail to report the number of patients who could not be followed up in each category. Considering the very low proportion of the study population who was classified in the “new or presumed new LBBB” category, it is clear that the result may be completely different if the contribution of the “new or presumed new

Update

American Journal of Emergency Medicine

Volume 28, Issue 8, October 2010, Page 981

DOI: https://doi.org/10.1016/j.ajem.2010.07.012

Errata 981

Gilbert A. Leidig MD Anthony W. Clay DO John J. Kelly MD Ehsanur Rahman MD Section of cardiology department of Medicine

Christiana Care Health System Newark, DE 19718

DOI of original article: 10.1016/j.ajem.2009.09.005 doi:10.1016/j.ajem.2010.07.011

In the article “Timely identification of bacterial pathogens may reduce inappropriate antibiotic prescription” in the American Journal of Emergency Medicine 2010;28(4):519-520, there was an error in the byline. Dr Jolobe was incorrectly listed as an MD. The Correct byline is below.

Oscar M.P. Jolobe MB, ChB

DOI of original article: 10.1016/j.ajem.2010.01.022 doi:10.1016/j.ajem.2010.07.012

In the article “The differential diagnosis includes reversible cerebral vasoconstrictor syndrome” in the American Journal of Emergency Medicine 2010;28(5):637, there was an error in the byline. Dr Jolobe was incorrectly listed as an MD. The correct byline is below.

Oscar M.P. Jolobe MB, ChB

DOI of original article: 10.1016/j.ajem.2010.03.030 doi:10.1016/j.ajem.2010.07.013

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