A bolt from the blue; A case report of an unusual asthma exacerbation.

BACKGROUND: We describe this case of a young gentleman presenting with acute dyspnoea on a background history of known, long-standing asthma. His dramatic presentation, notable for profound hypoxia and cyanosis, led to an unexpected additional diagnosis of type one congenital methaemoglobinaemia. CASE PRESENTATION: A 26-year-old Irish gentleman was transferred urgently to the emergency department resuscitation room with marked cyanosis and tachypnoea. His oxygen saturation was 70% on 100% high flow oxygen. His arterial blood gas (On Fi02 90%) demonstrated a PaO2 = 76.8 kPa, SpO2 = 99%, pCO2 = 3 kPa and pH = 7.51. A saturation gap was evident and on further analysing the arterial blood gas, the methaemoglobin level was noted to be 28%. No contributing drugs were identified. Our patient was diagnosed with type one congenital methaemoglobinaemia. He recovered well from this admission, however, has had recurrent presentations to hospital since with high methaemoglobin levels noted on each occasion. DISCUSSION: Congenital methemoglobinemia is a rare, often overlooked differential diagnosis in patients presenting with cyanosis and dyspnoea. This is the only case, to our knowledge, of a patient with both asthma and congenital methaemoglobinaemia. Congenital methaemoglobinaemia was first described in 1943 by Dr Deeny who described two siblings as suffering from 'Familial Idiopathic Methaemoglobinaemia'. The case we present is the first reported Irish case of congenital methaemoglobinaemia, we are aware of, since 1943.Current treatment strategies include high-flow oxygen, methylene blue infusion (contraindicated in glucose-6-phosphate-dehydrogenase deficiency) and red cell exchange transfusions in the emergency setting whilst oral ascorbic acid and riboflavin are preventative.

Biannual otolith-zone formation of young shallow-water hake Merluccius capensis in the northern Benguela: age verification using otoliths sampled by a top predator.

Otoliths collected at least monthly from scat samples of Cape fur seals Arctocephalus pusillus are used to show that shallow-water hake Merluccius capensis from the northern Benguela develop three translucent zones in their first 1·5 years of life. The novel sampling approach provided otoliths that belonged to four M. capensis cohorts of approximate known age (hatched in 1996, 1998, 2002 and 2005), allowing age verification. Following spawning in austral winter, translucent zones consistently formed first in summer and autumn (T1), then in winter and spring (T2) and again in summer and autumn (T3), with no difference in appearance of the zones (biannuli) for the four cohorts considered. The second translucent zone is usually the first true annulus (year mark). It forms during July to September in fish of 15-20 cm total length (LT ). Formation of the translucent zones appears to be determined by fish length or age, rather than by exogenous cues. It is suggested that length measurements should be used to help determine the first age group; fish with a translucent zone marked at otolith lengths >7·5 mm should be termed 1 year-old fish. Ages of M. capensis used in previous stock assessment models have been overestimated. Biannuli are an unusual occurrence in fish otoliths in general, but have been observed in other Merluccius species.

Increase in alcohol related deaths: is hepatitis C a factor?

AIM: To evaluate recent trends in alcohol related deaths in the UK and to consider possible causative factors. DESIGN: Observational retrospective study of the database of the Office for National Statistics, alcohol consumption data reported by the General Household Survey, and other published data. SETTING: England, 1993-9. RESULTS: Deaths for each million of the population from alcohol related illness increased by 59% in men and 40% in women over the years 1993 to 1999. One subgroup of alcohol related deaths, ICD 571.3 (alcoholic liver damage unspecified), showed a 243% increase in men aged 40 to 49 years over the same period. Figures for younger men, and women in all age groups, showed less pronounced increases. There has been no associated rise in alcohol intake. There has been an increase in the incidence of hepatitis C virus (HCV) infection in recent years, and alcohol consumption in HCV positive individuals accelerates the progression to cirrhosis. Circumstantial evidence links the rise in HCV infection to the use of illicit drugs in the 1970s and 1980s, among those currently aged 40 to 59 years. CONCLUSIONS: The recent increase in alcohol related deaths cannot be solely explained by a change in drinking habits. It is suggested that this probably results from the rapid progression of alcoholic cirrhosis in people who have acquired HCV infection through intravenous drug use. Alcohol consumption in HCV positive individuals is firmly linked with a poor outcome.

Radiographic resolution of lymphocytic interstitial pneumonitis (LIP) in children with human immunodeficiency virus (HIV): not a sign of clinical deterioration.

BACKGROUND: The literature and anecdotal evidence associate the resolution of radiographic findings of lymphocytic interstitial pneumonitis (LIP) with a decline in immune and clinical status of human immunodeficiency virus (HIV) infected children. OBJECTIVE: As our clinical impression was the opposite, we sought to elucidate this contradiction. MATERIALS AND METHODS: Of 52 pediatric patients infected with the HIV currently being followed at our institution, 20 (38.5%) carried the diagnosis of LIP and 13 (65%) of these have had complete resolution of radiographic findings of LIP. We retrospectively reviewed the chest radiographs, CD4 counts, and clinical history of these 13 patients. RESULTS: Of the 13 patients who had resolution of radiographic findings, 11 (84.6%) had no significant change in CD4 count at the time of resolution and remained clinically stable during a mean follow-up period of 32 months. Two patients (15.3%) developed severe CD4 lymphocytopenia at the time of resolution of LIP, but clinically remained stable. None of these 13 patients had a recurrence of LIP, even with subsequent increases in CD4 count. CONCLUSION: We suggest that in contradiction to previously published data, resolution of LIP on chest radiographs is not an indicator for poor prognosis for the HIV-infected pediatric patient.

Cyclospora species--a cause of diarrhoea among Irish travellers to Asia.

We report three cases of travellers' diarrhoea caused by Cyclospora cayetanensis. These demonstrate the importance of cyclosporiasis as a cause of diarrhoea in Irish travellers to Nepal and Pakistan and its effective treatment with co-trimoxazole. Laboratory staff must measure the size of oocysts in stool samples to properly identify this protozoan.