- Volume 2, Issue 5, 2015

Ireland currently has the highest reported rate in Europe of vancomycin-resistant Enterococcus (VRE) isolated from the bloodstream, but data regarding the prevalence of VRE endocarditis remain scarce. Treatment options for Enterococcus-mediated endocarditis are limited, and therefore daptomycin is commonly used off licence in this setting.

A 60-year-old male with end-stage kidney disease (ESKD) presented with VRE bacteraemia secondary to a gangrenous right foot colonized with vancomycin-resistant Enterococcus faecium. Aortic valve endocarditis was confirmed using transoesophageal echocardiography. Treatment was commenced with linezolid and subsequently modified to combination therapy with daptomycin and rifampicin. High-dose daptomycin therapy was employed unsuccessfully and, after 20 days of therapy, daptomycin resistance emerged, which proved fatal.

The case was ethically challenging and involved a refusal of amputation and, ultimately, any form of treatment by the patient. In summary, however, daptomycin-resistant VRE bacteraemia complicated by recalcitrant daptomycin-resistant VRE endocarditis proved fatal for this patient. Further evaluation of the efficacy and safety of high-dose daptomycin for the treatment of VRE infective endocarditis is needed.

Rotavirus infection is usually localized to the intestine. Severe cases with extraintestinal symptoms are rare, and its pathogenesis remains unclear.

We report severe rotavirus infections in five previously healthy, unvaccinated children that occurred in the 2011 season in Aichi Prefecture, Japan. All cases had short histories of recurrent diarrhoea and vomiting that preceded extraintestinal symptoms. Two cases with prolonged seizures and unconsciousness were diagnosed with encephalitis/encephalopathy; one case died and the other survived with severe neurological sequelae in spite of intensive treatment including anticytokine therapy. Another two cases had rapidly worsening cardiopulmonary dysfunction and seizures, and they died a few hours after admission despite cardiopulmonary support. The last case was transferred to hospital in cardiopulmonary arrest and resuscitation was unsuccessful. All cases had positive stool samples for rotavirus RNA, and the rotavirus antigen was also detected in the serum of four cases, but not in the cerebrospinal fluid (CSF). Serum IL-6 and IL-10 levels were significantly higher in the severe cases than in children with rotavirus gastroenteritis without extraintestinal symptoms, and serum IL-10 levels were significantly higher than CSF levels in the severe cases.

Cytokines appear to mediate the pathogenesis of severe rotavirus infection with extraintestinal involvement. In conclusion, these cases highlight the need for a routine rotavirus immunization programme.