was again recovered from blood cultures (5/5 bottles). = 3.2?g/L Moexipril hydrochloride (normal 6.9?g/L) and IgA = 0.4?g/L (normal 0.88?g/L). was isolated from blood cultures, Plxnd1 but not from the fecal culture. Azithromycin was initiated for a total duration of 2 weeks. One month later, the patient presented with a novel septic state, this time associated with abdominal cutaneous cellulitis. was again recovered from blood cultures (5/5 bottles). Initial antibiotherapy (piperacillin-tazobactam) was again Moexipril hydrochloride replaced by azithromycin for a duration of 4 weeks. Substitution treatment with monthly intravenous immunoglobulins (IVIg) was initiated, and a residual level of 6?g/L was obtained. No relapse was noted after more than 12 months of followup. Patient 2 A 58-year-old man with SHARP syndrome (mixed connective tissue disease with predominant autoimmune myositis) and hypogammaglobulinemia secondary to immunosuppressive treatment (cyclophosphamide, mycophenolate mofetil, and rituximab) was hospitalized for sepsis associated with cellulitis of the left upper arm, without any obvious clinical source. His hemogram was unremarkable (neutrophils = 16?giga/L). The patient had already received monthly IVIg substitution for 4 years and had an IgG level of 6?g/L and IgA of 1 1.05?g/L at the time of appearance of the infection. Blood cultures (5/5 bottles) were positive for (2/2 bottles). She was Moexipril hydrochloride successfully treated with ceftriaxone 2?g/day followed by oral ciprofloxacin (1000?mg/day) for a total duration of 3 weeks. Treatment with IVIg was continued with the aim of achieving a residual level of 6?g/L, but at 2 months she presented with a new episode of severe sepsis due to leading to death. 3. Discussion We report three cases of severe bacteremia developing in the setting of acquired immunosuppression with hypogammaglobulinemia. These opportunistic infections are a real concern for the clinician since bacteremia often involves extraintestinal localizations [1, 2, 5]. species identified in the general population, is more often found in immunosuppressed patients where it represents more than one-half of cases [2]. As in our patients, this species also appears to be more common in elderly patients, as reported by Pacanowski et al. (median age 69.5 years versus 55.6 for other species of postthymectomy [1]. Other studies then demonstrated the association between hypogammaglobulinemia and infection with different species [2]. More recently, Oksenhendler et al. found 19 cases of common variable immunodeficiency (CVID) in a series of 252 infections, and measurement of immunoglobulins in these patients revealed undetectable levels of IgA and IgM [4]. This hypogammaglobulinemia, which usually affects IgA, could favor infections due to the important role of these immunoglobulins in the anti-infectious defense of the body at the level of the digestive mucous membranes. The digestive tract is the usual route of contamination by infection reported in the literature [2, 5]. In the cohort reported by Pacanowski et al., diarrhea was found in only 33% of cases and cellulitis in 19% (versus 7% cellulitis for the other species) [2]. These data agree with the clinical presentation in our three patients who all presented with cellulitis-type cutaneous symptoms, without any digestive signs. The evolution of the patients in terms of mortality depends on the underlying disease and also on the initial choice (adapted or not) of antibiotherapy. is often resistant to quinolones and macrolides, and some authors recommend the use of imipenems as first-line treatment [1, 2]. In the series of 178 patients described by Pacanowski et al., no strain of was resistant to imipenems, while 32% were resistant to fluoroquinolones, and no patient on imipenem had died at 30-day followup [2]. In contrast, resistance to erythromycin and the combination amoxicillin-clavulanic acid was more often found with Moexipril hydrochloride other species [2]. Bacteremia due to readily recurs with atypical Moexipril hydrochloride symptoms and requires prolonged antibiotherapy [2, 5]. Multiple factors, including the duration of antibiotherapy, probably favor these relapses, but hypogammaglobulinemia could also be a risk factor for relapse even in cases of.
was again recovered from blood cultures (5/5 bottles)