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We report the case of a 51 year-old female who complained of jaundice and weight loss. At the time of presentation, she had been in remission from a stage 2a ductal breast carcinoma for 58 months. The clinical presentation was suggestive of a primary pancreas cancer with liver metastases and retroperitoneal lymph nodes. We performed liver and pancreas biopsies that demonstrate a relapse of her old breast carcinoma with positive hormone receptors and HER2 positive. Conservative treatment by chemotherapy was given with Paclitaxel - Trastuzumab and Pertuzumab. Pancreatic metastases are uncommon. Furthermore, pancreatic metastases from breast cancer are very rare. We performed a review of the literature and found 48 cases of pancreatic metastases from breast cancer. We would like to highlight by this case that when a pancreatic lesion appears, in patients with a past history of cancer, physicians must not forget the possibility of metastases from primary tumor even if the initial stage, of the tumor, is low. However the diagnosis is not always easy. If liver and pancreatic lesions occur simultaneously, the clinical presentation can mimic metastatic primary pancreatic cancer. Therefore performing biopsy is highly recommended for making the correct diagnosis and also for the staging of the disease and the choice of the best treatment according to immunohistochemical analysis.

Infective endocarditis (IE) is a rare but serious illness associated with a high mortality. Staphylococcus spp and Streptococcus spp are the most frequent causative pathogens. In this study, we compared the epidemiology, clinical characteristics and outcomes of patients with Staphylococcal and Streptococcal IE in a tertiary hospital. Using our institutional database 'Medical Explorer', we collected all cases of IE retrospectively between January 2005 and December 2010 at the Cliniques Universitaires Saint Luc and then focused on Staphylococcal and Streptococcal IE. Of the 212 patients with IE included in our study, Staphylococcus spp accounted for 35.9% (76/212) of the cases, Streptococcus spp for 35.4% (75/212) and the remainder 18% (61/212) of cases were caused by other pathogens. Negative blood culture IE accounted for 10.4% of all cases. Demographic and clinical characteristics such as age, gender, fever, presence of a heart murmur, heart failure, nature of the affected valve, location of the endocarditis, duration of antibiotics, length of stay and complication were not different when comparing Staphylococcal and Streptococcal IE; only mortality differed. The mortality rate was 21.4 and 6.6% (p = 0.02) for Staphylococcal and Streptococcal IE, respectively. In the multivariate analysis, age 60 years, Staphylococcal IE, presence of complications and absence of surgery were independent risk factors for mortality.

BACKGROUND: Outpatient parenteral antibiotic therapy (OPAT) was not used in Belgium before 2013, except for patients with cystic fibrosis. Thus, we have performed a pilot study to evaluate clinical characteristics and outcomes of patient receiving OPAT in a Belgian setting. METHODS: The study was a prospective observational single-center study of patients receiving OPAT between 1 September 2013 and 31 December, 2017. RESULTS: We included 218 OPATs. The median age was 58 years and 71% were men. At the end of the treatment, 92% of the patients on OPAT were cured. Risk factors for treatment failure were obesity, diabetes and diabetic foot infections, longer duration of hospitalization before OPAT, and duration of OPAT >16 days. An average of 24 days of hospitalization per patient discharge was saved, which amounted to 5205 days saved during the project. During the OPAT and 30 days thereafter, 71 (32.6%) of patients were readmitted, but only 26 (12%) readmissions were directly related to OPAT. Risk factors for readmissions were diabetes and diabetic foot infections, endovascular infections, longer duration of hospitalization before OPAT, duration of OPAT >30 days, and history of hospitalizations in the year before OPAT. There were 2.3 intravenous catheter-related events per 1000 days of catheter use. Patients' level of satisfaction was high (99.5%) Conclusions: In this pilot study, OPAT is found to be efficacious in saving hospitalization's days, with a low rate of readmissions and complications and a high patients' level of satisfaction. We therefore conclude that OPAT is feasible and safe Background: Outpatient parenteral antibiotic therapy (OPAT) was not used in Belgium before 2013, except for patients with cystic fibrosis. Thus, we have performed a pilot study to evaluate clinical characteristics and outcomes of patient receiving OPAT in a Belgian setting. METHODS: The study was a prospective observational single-center study of patients receiving OPAT between 1 September 2013 and 31 December, 2017. RESULTS: We included 218 OPATs. The median age was 58 years and 71% were men. At the end of the treatment, 92% of the patients on OPAT were cured. Risk factors for treatment failure were obesity, diabetes and diabetic foot infections, longer duration of hospitalization before OPAT, and duration of OPAT >16 days. An average of 24 days of hospitalization per patient discharge was saved, which amounted to 5205 days saved during the project. During the OPAT and 30 days thereafter, 71 (32.6%) of patients were readmitted, but only 26 (12%) readmissions were directly related to OPAT. Risk factors for readmissions were diabetes and diabetic foot infections, endovascular infections, longer duration of hospitalization before OPAT, duration of OPAT >30 days, and history of hospitalizations in the year before OPAT. There were 2.3 intravenous catheter-related events per 1000 days of catheter use. Patients' level of satisfaction was high (99.5%) Conclusions: In our study, OPAT is found to be efficacious in saving hospitalization's days, with a low rate of readmissions and complications and a high patients' level of satisfaction. We therefore conclude that OPAT is feasible and safe.

We present the updated Belgian guidelines for the use of non-occupational HIV post-exposure prophylaxis (NONOPEP). This document is inspired by UK guidelines 2015, adapted to the Belgian situation and approved by all AIDS reference centers in Belgium. When recommended, NONOPEP should be initiated as soon as possible, preferably within 24 h of exposure but can be offered up to 72 h. The duration of NONOPEP should be 28 days. These current guidelines include epidemiologic estimations, which can be used to calculate the risk of infection after a potential exposure and help to decide whether or not to start prophylaxis. We review which medications to use in the context of the last Belgian NONOPEP convention, provide a checklist for initial assessment, and make recommendations for monitoring individuals receiving NONOPEP.

A 64-year-old man with a history of sarcoidosis on corticosteroids and azathioprine was admitted to our hospital with complaints of worsening left knee pain and swelling for the past 3 weeks. His past medical history is also significant for severe osteoarthritis requiring a cemented total left knee arthroplasty 1 year ago. Diagnostic investigation during his hospital admission eventually led to the diagnosis of Nocardia nova knee prosthetic joint infection in the setting of a disseminated nocardiosis. He was successful treated by one-stage complete hardware exchange in conjunction with an adapted antibiotic therapy regimen (meropenem and doxycycline followed by ceftriaxone and doxycycline). Two years later, his recovery was deemed excellent.

BACKGROUND: Antiretroviral therapy reduces mortality and morbidity in HIVinfected individuals, most markedly when initiated early, before advanced immunodeficiency has developed. Although the international guidelines recommend starting antiretroviral therapy ART with a high CD4 cell count level, in the practice, this is particularly challenging to achieve, especially in late presentation of HIV diagnosis. The aim of this study was to determine the frequency and the demographic features associated with late presentation for HIV diagnosis in our Centre. METHODS: All newly diagnosed patients with HIV between January 2007 and December 2011 in our AIDS Reference Centre, were included. Late presenter patient was defined as patient with CD4 count 350/mm(3) at the time of diagnosis. Demographic age, sex, ethnicity, migration and clinical characteristics transmission mode, CD4 cell count, viral load were collected. We also collected data on outcome median day of hospitalization, mortality, virological response to ART and lost to followup LTFU. LTFU was defined as patient without any medical contact and viral load measurements during two consecutive years in our centre. RESULTS: From 2007 to 2011, 154 429 out of 359 patients newly diagnosed with HIV were late presenters. According to univariate analysis, age 50, female gender, migrant from subSaharan Africa and heterosexual contact were associated with late presentation for HIV diagnosis. In the multivariate analysis, age 50, heterosexual contact and migrant status particularly women were the only independent risk factors for late presentation. Late presenters tend to have a worse outcome than nonlate presenters. CONCLUSION: A considerable proportion of patients continue to be diagnosed with advanced HIV disease, despite the fact that risk factors for late presentation have been clearly identified. Despite high testing rate for HIV in Belgium, highrisk population like migrant, heterosexual contact, remain under tested. In order to be able to detect and treat all patients with high CD4 cell count as recommended by all international guidelines, we recommend developing testing policies specifically focused on these categories at high risk for late presentation.

Background and objective: There has been a marked increase in tourism, immigration, and business travel to malaria-endemic areas. Non-immune individuals (western travellers) or immigrants living for more than one year in non-endemic areas who visit friends and relatives (VFR) are particularly susceptible to developing severe malaria when travelling to areas with high levels of transmission. In this study, epidemiological, clinical and biological features of malaria in travellers returning from endemic areas were analysed. This may help clinicians unfamiliar with malaria not to overlook this disease in its early stage, and to initiate prompt treatment. Patients and methods: we retrospectively analysed all cases of patients who presented with malaria in our institution between 2003 and 2008. Results: Eighty patients were included. Most patients visited Africa (93.6%). Accordingly, P. falciparum was the main species identified (67/77 patients i.e. 87%). Sixty-five patients (65/78 i.e. 83.3%) had not taken any prophylaxis and 13 (16.7%) had taken it inadequately. Common clinical features were fever (80/80, 100%), influenza-like symptoms (16/80, 20.1%), respiratory symptoms (5/80, 6.3%), neurological symptoms (2/80, 2.5%) or digestive symptoms (15/80, 18.8%). Digestive symptoms were predominant in children < 16 y.o. (60% of these patients). Conclusion: Imported malaria cases are mostly related to the lack of adequate use of chemoprophylaxis. Plasmodium falciparum is the main species responsible for imported cases of malaria in our institution. Clinical features vary, but fever is universally present at presentation. As such, all cases of fever upon return from a malaria-endemic area must be considered as malaria until proven otherwise, at least during the first three months after the return

Dear editor,Infective endocarditis (IE) is a rare illness with high morbidity and mortality. In industrialized countries, the incidence is currently stable with about 6.2/100,000 in habitants per y...

Background: Septic arthritis (SA) is a rheumatological emergency that can lead to rapid joint destruction and irreversible loss of function. The most common pathogen causing SA is Staphylococcus aureus which is responsible for 37–65% of cases. Streptococcus pneumoniae is traditionally described as an uncommon cause of SA of a native joint. The objective of our study was to analyse clinical characteristics, treatment, and outcome of all cases of pneumococcal septic arthritis treated in our institution, and to compare them with other series published in the literature. Materials and methods: We conducted a retrospective study of pneumococcal SA identified among all cases of SA diagnosed in a teaching hospital of one thousand beds between 2004 and 2009. Diagnosis was based on culture of joint liquid or by the presence of pneumococcal bacteraemia and purulent (more than 50 000/mm3 white blood cells with more than 90% neutrophils) joint fluid aspiration. Results: Among 266 cases of SA, nine patients (3·3%) were diagnosed as having pneumococcal SA. The median age was 75 years. The main affected joint was the knee (7/9). No patient had more than one joint involved. Four patients suffered from concomitant pneumonia. Joint culture and blood cultures were positive in 7/9 and 5/9, respectively. Median (range) length of stay was 18 days (3–47 days). One patient with associated pneumococcal bacteraemia died 19 days after admission. Seven patients recovered completely. Conclusions: Streptococcus pneumoniae is now being increasingly recognized as a common agent of SA. This organism is frequently associated with pneumococcal pneumonia or bacteraemia, particularly in patients with advanced age and comorbidities. Direct inoculation of joint fluid into blood culture medium BACTEC system increases the probability of microbiological diagnosis. The prognosis is usually favourable if the disease is promptly recognized and treated (antibiotic therapy combined with joint drainage).

Leishmaniasis, an intracellular protozoal infection in which tissue macrophages are targeted, is transmitted by female sandfly bite and occurs in 98 countries. Visceral leishmaniasis (VL) is the clinical form of leishmaniasis most frequently associated with HIV, especially in Europe. Both diseases have a synergistic detrimental effect on the cellular immune response. Treatment of VL in patients with underlying HIV-infection is associated with lower cure rates, higher rates of drug toxicity, higher relapse rates and greater mortality than treatment of VL in immunocompetent patients. We report the case of a HIV-1 infected patient with advanced disease who presented VL with multiple relapses. This case highlights the difficulties of treating VL in patients with HIV co-infection.

BACKGROUND: Etravirine is a second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI) with a pattern of resistance mutations quite distinct from the current NNRTIs. METHODS: We collected all routine samples of HIV-1 patients followed in the AIDS reference laboratory of UCLouvain (in 2006 and 2007) carrying resistance-associated mutations to nevirapine (NVP) or efavirenz (EFV). The sensitivity to Etravirine was estimated using three different drug resistance algorithms: ANRS (July 2008), IAS (December 2008) and Stanford (November 2008). We also verified whether the mutations described as resistance mutations are not due to virus polymorphisms by the study of 58 genotypes of NNRTI-naive patients. RESULTS: Sixty one samples harboured resistance to NVP and EFV: 41/61 had at least one resistance mutation to Etravirine according to ANRS-IAS algorithms; 42/61 samples had at least one resistance mutation to Etravirine according to the Stanford algorithm. 48 and 53 cases were fully sensitive to Etravirine according to ANRS-IAS and Stanford algorithms, respectively. Three cases harboured more than three mutations and presented a pattern of high-degree resistance to Etravirine according to ANRS-IAS algorithm, while one case harboured more than three mutations and presented high degree resistance to Etravirine according to the Stanford algorithm. The V1061 and V179D mutations were more frequent in the ARV-naive group than in the NNRTI-experienced one. CONCLUSIONS: According to the currently available algorithms, Etravirine can still be used in the majority of patients with virus showing resistance to NVP and/or EFV, if a combination of other active drugs is included.

Campylobacter fetus is an opportunist Gram-negative bacillus. The most frequent clinical manifestation is bacteriemia but it can also be responsable for soft tissue infections, endovascular infections, meningitis, peritonitis and thrombophlebitis. Campylobacter fetus cellulitis has been described, but rarely identified in subcutaneous puncture samples. We report a case of an immunocompromised patient with Campylobacter fetus bacteriemia associated with a soft tissue infection whose subcutaneous puncture also revealed the bacteria.

Heparin-induced skin necrosis is an infrequent condition, complicating unfractionated heparin and more rarely low-molecular-weight heparin administration. Like heparin-induced thrombocytopenia, it is associated with the presence of anti-PF4 antibodies. After reporting 2 observations, we briefly review the clinical features and management of this condition. Early recognition is of the utmost importance since heparin-induced skin necrosis can be associated with HIT, a potentially lethal disorder.

(2009). PROSTATE ABSCESS FOLLOWING INTRAVESICAL BCG THERAPY. Acta Clinica Belgica: Vol. 64, No. 5, pp. 436-437.