Unusual presentation of erythema elevatum diutinum with underlying hepatitis B infection.

Erythema elevatum diutinum (EED) is a rare, chronic, cutaneous small vessel vasculitis of unclear pathogenesis. Classically, lesions present as symmetric red to purple plaques, papules, and nodules overlying joints. First-line therapy is dapsone. We present a case of EED with widespread lesions involving the hands, extensor arms and legs, and trunk. Multiple biopsies showed concentric intradermal perivascular inflammation with dermal fibrosis and leukocytoclastic vasculitis (LCV) suggesting EED in various stages of evolution. An extensive workup was positive for underlying hepatitis B infection. Our case represents the clinicopathologic spectrum that EED can present and emphasizes the importance of searching for an underlying etiology.

Nocardia Brain Abscess and CD4(+) Lymphocytopenia in a Previously Healthy Individual.

Nocardia brain abscesses are a known occurrence in patients with immunocompromised conditions. Nocardial infection is commonly an unfortunate sequela to other complications which these patients are being followed up and treated for. The incidence of nocardial brain abscess in an otherwise healthy patient is extremely rare. We present a case of Nocardia brain abscess in a previously healthy individual, who, upon workup for vision and gait abnormalities, was shown to have multiple brain abscesses and a decreased absolute CD4(+) lymphocyte count. Adding to the rarity of our case, the finding of lymphocytopenia in our patient was unrelated to any known predisposing condition or infectious state.

Selection of antiepileptic drugs in older people.

OPINION STATEMENT: Elderly people are one of the fastest-growing populations in the United States, and the incidence of epilepsy in older people is much higher than in other population subgroups. This age group is the most vulnerable because of the increased incidence of multiple medical comorbidities, including stroke. The diagnosis of epilepsy is extremely challenging and often delayed in this age group because of an atypical presentation. Seizures are manifest through extremely vague complaints, such as episodes of altered mental status or memory lapses. Once the diagnosis is established by careful history taking and diagnostic testing, anticonvulsants are the mainstay of treatment. The choice of anticonvulsants in elderly patients requires careful evaluation of medical comorbidities, which vary on an individual basis. This subgroup also is more susceptible to adverse effects because of the physiologic changes in the body due to older age, which affect the pharmacokinetics of most anticonvulsants. The ideal drug in this age group should have linear pharmacokinetics, fewer adverse effects, minimal or no drug-drug interactions, no enzyme induction/inhibition, a long half-life, and minimal protein binding, and should be cost-effective. As such, there is no ideal drug for this patient population, although both older- and newer-generation anticonvulsants are used for long-term treatment. Most newer anticonvulsants have the advantage of a favorable pharmacokinetic profile, minimal or no drug-drug interactions, and fewer adverse events, as well as being well tolerated. The older anticonvulsants still are widely used, because the newer anticonvulsants are much more expensive.