A triple tunnel from the mid-calf to the femoral vein in patient with severe dementia.

Achieving the ideal exit site is the new philosophy for complicated vascular access patients. Recent publications have described multiple venous access solutions such as tunneling to the scapular region, the chest to the arm, and from the femoral vein to the abdominal and patellar region. In the patients afflicted with delirium, dementia, or confusion even these sites may not be sufficient. The following case study illustrates a triple tunneled femoral catheter on a non-cooperative patient with inoperable endocarditis to be discharged and treated with long term antibiotics.

Atypical Case of Lyme Neuroborreliosis With Hyponatremia.

Lyme neuroborreliosis is diagnostically challenging because of its diverse manifestations. Literatures studies have documented a neurological spectrum that includes radiculoneuritis, lymphocytic meningitis, and cranial neuropathy in the early disseminated stage of Lyme's disease. Severe and refractory hyponatremia is a rare association with Lyme neuroborreliosis, further misleading clinicians to misdiagnose the syndrome of inappropriate antidiuretic hormone secretion (SIADH). This case report describes a 58-year-old woman who developed progressive lower extremity weakness and paresthesia, cerebellar ataxia, and persistent hyponatremia. The patient was hospitalized to rule out cerebral vascular stroke, Guillain-Barre, and SIADH. Lyme neuroborreliosis was diagnosed and treated with 2mg ceftriaxone from clinical suspicion. With treatment initiation, the patient's neurological symptoms of gait instability, hyponatremia, and bilateral lower extremities weakness gradually resolved.

Rare case of acute transverse myelitis associated with Lyme neuroborreliosis.

Acute transverse myelitis is a neurological disorder that leads to acute spinal cord injury due to inflammation caused by autoimmune disorders or by parainfectious etiologies. Among the many different infectious causes of transverse myelitis, one of the rare ones is Lyme disease. Here we describe a case of a 62 year old male who presents with bilateral paresthesia and weakness. MRI imaging of the cervical and thoracic spine led to the initial diagnosis of cervical cord edema leading to the symptoms associated transverse myelitis. However further workup of different infectious causes lead to positive Lyme titers with positive confirmatory ELISA testing. Initiation of Lyme disease treatment with IV ceftriaxone led to the gradual resolution of the symptoms.