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Journal-Club https://www.mdc-berlin.de/de/veroeffentlichungstypen/clinical- journal-club Als gemeinsame Einrichtung von MDC und Charité fördert das Experimental and Clinical Research Center die Zusammenarbeit zwischen Grundlagenwissenschaftlern und klinischen Forschern. Hier werden neue Ansätze für Diagnose, Prävention und Therapie von Herz-Kreislauf- und Stoffwechselerkrankungen, Krebs sowie neurologischen Erkrankungen entwickelt und zeitnah am Patienten eingesetzt. Sie sind eingelanden, um uns beizutreten. Bewerben Sie sich! A 53-year-old man presented to the infectious disease clinic with a 4-month history of progressively enlarging, painless nodules on his scalp and perianal region. He had undergone liver and kidney transplantation 2 years ago and was receiving tacrolimus, mycophenolate mofetil, and prednisolone for immunosuppression. What is the most likely diagnosis? Drug-induced reaction Malakoplakia Pyoderma gangrenosum Sarcoidosis Pyogenic granuloma The correct answer is malakoplakia. Cultures grew Escherichia coli and Pseudomonas aeruginosa. The patient underwent biopsy of his lesions, which identified basophilic inclusions characteristic of Michaelis-Gutmann bodies. These are pathognomonic for malakoplakia, which is a chronic granulomatous condition that can occur in immunocompromised patients. The patient was treated with antibiotics and a reduction in the immunosuppression regimen. The lesions regressed with some residual scarring. Als Malakoplakie bezeichnet man eine seltene chronisch entzündliche Erkrankung, die mit makroskopisch sichtbaren plaqueartigen oder tumorförmigen, weiß-grauen Ablagerungen meistens im Bereich von Nieren, Harnleitern oder der Harnblase einhergeht. Es kann auch zu einer diffusen Infiltration des Nierenparenchyms kommen. Die Plaques entstehen vorwiegend im Rahmen chronischer Harnwegsentzündungen, meist aufgrund von Colibakterien. Oft liegt zusätzlich eine Abwehrschwäche (Immundefekt) oder ein Tumorleiden vor. Seltener sind andere Organe wie Magen-Darm-Trakt, Lunge oder Haut betroffen. Das histologische Korrelat sind große, polygonal geformte Makrophagen mit schaumigem, eosinophilem Zytoplasma (von Hansemann-Zellen). Pathognomonisch sind PAS-positive, körnchenförmige Mikrofoto von Malakoplakie mit Ablagerungen (Granula), die als Michaelis Gutmann Körperchen Michaelis-Gutmann-Körperchen (HE- bezeichnet werden. Man nimmt an, dass die Michaelis Gutmann Färbung) Körperchen die Reste von Phagosomen darstellen, die Die Malakoplakie ist eine chronisch- unvollständig verdaute Bakterien sowie Ablagerungen von entzündliche granulomatöse Calcium und Eisen enthalten. Der zugrunde liegende Zelldefekt Multisystem-Erkrankung und ist wahrscheinlich die verminderte Fähigkeit, aufgenommene gekennzeichnet durch einzelne oder Bakterien abzutöten. Charakteristische Symptome sind hohes multiple weiche Plaques auf Fieber, Flankenschmerz und eventuell ein tastbarer Tumor. Auch verschiedenen Organen des Körpers. akutes Nierenversagen wurde beschrieben. Häufig wird zunächst an einen bösartigen Tumor von Niere oder ableitenden Harnwegen gedacht, bis die feingewebliche Untersuchung die Diagnose beweist. Die Diagnostik der Malakoplakie umfasst Urinkultur, Blutkultur, bildgebende Diagnostik sowie eine Zystoskopie mit Biopsie der Läsionen. Die Therapie der Malakoplakie erfolgt mit Langzeitantibiose (Fluorchinolonen) oder chirurgischer Sanierung. Das Pyoderma gangraenosum, auch Dermatitis ulcerosa genannt, ist eine schmerzhafte Erkrankung der Haut, bei der es großflächig, in der Regel an einer Stelle, zu einer Geschwürbildung (Ulzeration oder Ulkus) und zu einem Absterben (Gangrän) der Haut kommt. Die Erkrankung wird nicht durch eine Infektion verursacht, weshalb die Behandlung mit Antibiotika wirkungslos ist, sondern wahrscheinlich durch eine überschießende Reaktion des Immunsystems (Autoimmunerkrankung). Dabei kommt es zu einer Neutrophilenaktivierung, welche nicht durch Gewebe-Proteinaseinhibitoren ausreichend reguliert wird. Sie wird daher auch mit Immunsuppressiva, wie beispielsweise Glucocorticoiden, Dapson oder Cyclosporin A, behandelt, die das Immunsystem unterdrücken. Das Pyoderma gangraenosum tritt teilweise im Rahmen anderer vorbestehender Erkrankungen auf, beispielsweise bei Morbus Crohn, Colitis ulcerosa, rheumatischen Erkrankungen wie Rheumatoider Arthritis und Vaskulitiden, Leukämien oder chronischer Leberentzündung (Hepatitis). Außerdem kann ein Pyoderma gangraenosum nach Hautverletzungen in Erscheinung treten oder zur gangränösen Transformation von Operationswunden führen, so dass diese durch starke Immunsuppressiva behandelt werden müssen. Kontraindiziert sind iodhaltige Medikamente. Während die Krankheit sich in vielen Fällen langsam entwickelt, kann es zu massiven Ausbrüchen kommen, welche auch Amputationen erforderlich machen können. Die häufigste Lokalisation des Pyoderma gangraenosum ist die Vorderseite des Unterschenkels. Es kann aber auch an jeder anderen Stelle der Haut auftreten. Die Sarkoidose (von griechisch σαρκωειδής sarkoeidés ‚fleischartig‘, ‚fleischig‘), auch als Morbus Boeck (buːk) oder Morbus Schaumann-Besnier bezeichnet, ist eine systemische Erkrankung des Bindegewebes mit Granulombildung, die meistens zwischen dem 20. und 40. Lebensjahr auftritt. Die genaue Ursache der Krankheit ist bis heute unbekannt. Bei der Sarkoidose bilden sich mikroskopisch kleine Knötchen (Granulome) in dem betroffenen Organgewebe, verbunden mit einer verstärkten Immunantwort. Bei der Sarkoidose bilden sich mikroskopisch kleine Knötchen (Granulome) in dem betroffenen Organgewebe, verbunden mit einer verstärkten Immunantwort. Man unterscheidet eine zunächst akut verlaufende Form der Sarkoidose, das sogenannte Löfgren- Syndrom, von der schleichend und symptomarm einsetzenden chronischen Verlaufsform. In Deutschland tritt die Sarkoidose in 20 bis 30 Fällen auf 100.000 Einwohner auf. Erstmals war sie von Ernest Besnier und Cæsar Peter Møller Boeck in den Jahren 1889 und 1899 als Hauterkrankung beschrieben worden. Im Jahre 1924 erkannte Jörgen Nilsen Schaumann, dass es sich hierbei um eine systemische Erkrankung verschiedener Organe handelt. Der Schwede Sven Halvar Löfgren beschrieb 1953 die nach ihm benannte akute Verlaufsform. Tofacitinib (JAK STAT inhibitor) Treatment and Molecular Analysis of Cutaneous Sarcoidosis. NEJM Dec. 2018 Das pyogene Granulom (lat Granuloma pyogenicum) ist ein erworbener gutartiger vaskulärer Hauttumor aus der Gruppe der Hämangiome. Es handelt sich um eine exophytische Gefäßproliferation. Dieser stark proliferierende Tumor (eine Hyperplasie) wird häufig als maligner Tumor (Krebs) fehlgedeutet. Das pyogene Granulom hat kein spezifisches histologisches Erscheinungsbild. Daher erhielt es in der Vergangenheit eine Vielzahl von Namen, unter anderem Granuloma pediculatum, Pediculatum, Epulis granulomatosa, Granuloma teleangiectaticum, Epulis angiomatosa, Wundgranulom, Stielknollen, Teleangiectaticum, Pseudobotryomykom, teleangiektatisches Wundgranulom, eruptives Angiom und proliferierendes Angiom. Die weit verbreitete Bezeichnung pyogenes Granulom ist ein Namensirrtum (Misnomer), da es sich nicht um eine Infektion bakterieller Natur (pyogen = ‚Eiter bildend‘), sondern um eine entzündliche Hyperplasie handelt. Auch die Bezeichnung Granulom ist genau genommen falsch. Einige Autoren bevorzugen daher die Bezeichnung lobuläres kapilläres Hämangiom (engl. lobular capillary hemangioma, LCH), während andere Autoren beim pyogenen Granulom zwei Unterarten unterscheiden: besagtes lobuläres kapilläres Hämangiom und einen Nicht-LCH-Typ (non- LCH). Beide Subtypen unterscheiden sich in ihrer Histologie. Ein großes pyogenes Granulom am linken Oberschenkel einer 28-jährigen Patientin mit HIV. Bakterielle Endokarditis 2 Major 1 Major + 3 Minor 0 Major + 5 Minor Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Patients with infective endocarditis on the left side of the heart are typically treated with intravenous antibiotic agents for up to 6 weeks. Whether a shift from intravenous to oral antibiotics once the patient is in stable condition would result in efficacy and safety similar to those with continued intravenous treatment is unknown. In a randomized, noninferiority, multicenter trial, we assigned 400 adults in stable condition who had endocarditis on the left side of the heart caused by streptococcus, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci and who were being treated with intravenous antibiotics to continue intravenous treatment (199 patients) or to switch to oral antibiotic treatment (201 patients). In all patients, antibiotic treatment was administered intravenously for at least 10 days. If feasible, patients in the orally treated group were discharged to outpatient treatment. The primary outcome was a composite of all- cause mortality, unplanned cardiac surgery, embolic events, or relapse of bacteremia with the primary pathogen, from the time of randomization until 6 months after antibiotic treatment was completed. For a large proportion of patients, the main reason for staying in the hospital after the initial phase is to complete intravenous antibiotic treatment. Therefore, if oral antibiotic treatment might be safe and efficient, part of the treatment period for patients in stable condition could take place outside hospitals, without the need for an intravenous catheter. Kaplan–Meier Plot of the Probability of the Primary Composite Outcome. The primary composite outcome was all-cause mortality, unplanned cardiac surgery, embolic events, or
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