Tick-borne relapsing fever in the northwestern United States and southwestern Canada.

Records from 182 cases of tick-borne relapsing fever (TBRF) were reviewed. In confirmed cases, there was febrile illness, and spirochetes were identified on peripheral blood preparations. In probable cases, there were clinical features of TBRF and either the same exposure as a confirmed case or serological (indirect fluorescent antibody test and western blotting [WB]) evidence of infection with Borrelia hermisii. Sera also were tested for antibody to Borrelia burgdorferi. We identified 133 confirmed and 49 probable cases of TBRF. A Jarisch-Herxheimer reaction was reported in 33 (54.1%) of 61 cases for which this information was available. Most patients who had antibodies to B. hermsii were serologically positive for B. burgdorferi, and WB demonstrated false positivity of testing for B. burgdorferi. Thirty-five (21%) of 166 cases were unreported to public health authorities. In 52 cases, there were more than two relapses before the diagnosis. This study demonstrates that TBRF is underrecognized and underreported and may be falsely identified as Lyme disease.

Renal microangiopathy in the primary antiphospholipid syndrome: a case report with literature review.

We report the case of a 52-year-old male patient with recurrent thrombosis from 'primary antiphospholipid syndrome' who developed renal microangiopathy. Despite anticoagulant therapy with coumadin, serum creatinine progressively increased from 398 to 592 mumol/l and platelets decreased to 43,000. The patient responded to high-dose methylprednisolone and aspirin and the renal function improved. A review of the literature disclosed 4 other cases of association between primary antiphospholipid syndrome and renal microangiopathy. The clinical characteristics of these cases are discussed.

Transient syndrome of inappropriate antidiuretic hormone secretion during pregnancy.

Plasma osmolality normally decreases in early pregnancy, reaching a minimum at approximately 10 weeks and remaining depressed until term. This is associated with a mean decrease of 4 mEq/L in the plasma sodium level, and with an altered threshold for arginine vasopressin (AVP) release and for thirst. We describe a patient who developed more severe hyponatremia (120 mEq/L), which accompanied the development of hypertension and edema at 37 weeks in her fourth pregnancy. Hyponatremia and hypo-osmolality were associated with marked elevation of the plasma AVP level. The hyponatremia and elevated AVP level resolved after the delivery of the infant. To our knowledge, this is the first reported example of transient inappropriate antidiuretic hormone secretion (SIADH) associated with pregnancy.

Cyclosporine A for the treatment of necrotizing scleritis and corneal melting in patients with rheumatoid arthritis.

Two of the ocular complications of rheumatoid arthritis (RA), necrotizing scleritis and keratolysis, have been associated with poor response to standard ocular therapy, and thus poor ocular outcome. We describe 6 patients with active ocular disease and active RA who failed to respond to disease modifying agents or immunosuppressive therapy and whose ocular and arthritic disease subsequently responded to cyclosporine A. Drug related complications were consistent with those reported for patients receiving similar doses for RA.

Acute hemolysis and renal failure following discontinuous use of rifampin.

Rifampin is frequently used in the treatment of mycobacterial infections. Intermittent or discontinuous therapy with rifampin has been associated with systemic symptoms referred to as the "flu syndrome" and, less frequently, acute hemolysis and acute renal failure. We report the case of a 73-year-old woman who experienced acute hemolysis and renal failure while being treated with rifampin and ethambutol for a respiratory infection caused by Mycobacterium fortuitum and M. avium-intracellulare. This patient had interrupted her therapy for periods of one week or more due to a rash and flu-like symptoms, which she ascribed to her medications. A review of the literature indicated that these adverse effects of rifampin appear to be immunologically mediated and that the symptoms of the flu syndrome may be due to mild intravascular hemolysis. Intermittent therapy with rifampin should be avoided and noncompliant patients should be given alternative treatment when possible.

Hyposplenia in a patient with systemic lupus erythematosus.

During the course of systemic lupus erythematosus in a young female patient the peripheral blood smear incidentally showed the features of hyposplenism. Silent lupus vasculitis with splenic infarction was suspected as the cause of this.