The first case of bacillus Calmette-Guérin-induced small-vessel central nervous system vasculitis.

To present an unrecognized vascular complication of bacillus Calmette-Guérin (BCG) therapy administered for superficial bladder carcinoma. We also review the potential mimickers for primary angiitis of the central nervous system (PACNS) as well as complications of intravesical BCG therapy. An 89-year-old Caucasian man with a history of relapsing high-grade bladder carcinoma treated with intravesical BCG presented with recurring episodes of right upper limb paresthesia with clumsiness and dysarthria. Magnetic resonance imaging of the head revealed multiple predominantly left-sided frontotemporal micronodular peri-vascular lesions. Left frontal lobe biopsy showed non-necrotizing granulomatous vasculitis. Ziehl staining was negative. Initially, he was treated for PACNS but his symptoms relapsed during every attempt to taper the corticosteroids. Six months later, he developed bilateral mycobacterial endophthalmitis, caused by Mycobacterium bovis. Brain biopsy was reviewed and confirmed the presence of perivascular mycobacteria. A retrospective diagnosis of BCG-induced central nervous system vasculitis was made and he was treated with high-dose corticosteroids, moxifloxacin, isoniazid, ethambutol, and rifampicin. BCG is a live attenuated form of Mycobacterium bovis widely used as tuberculosis vaccination and intravesical therapy for superficial forms of bladder cancer. Systemic complications affect roughly 5% of patients and can manifest months or years after the last instillation. Cases of endophthalmitis, meningitis, aortitis, or mycotic aneurysms have been described, but no reports of CNS vasculitis have been found. In disseminated forms of BCG infections, referred to as BCGitis, histopathology usually reveals granulomatous inflammation. Mycobacterial cultures are often negative, making this a diagnostic challenge. This is the first documented case of BCG-induced small-vessel CNS vasculitis. Mycobacterium bovis infection is rare and findings are often nonspecific, making the diagnosis very difficult. Other infectious and non-infectious causes must be ruled out appropriately before considering this entity.

Indications for and clinical procedures resulting from magnetic resonance imaging of the knee in older patients: Are we choosing wisely?

OBJECTIVE: To analyze the indications for and clinical procedures resulting from knee magnetic resonance imaging (MRI) in older patients. DESIGN: We retrospectively analyzed 215 medical records of patients 50 years of age and older who had undergone a unilateral knee MRI in 2009. SETTING: Centre hospitalier universitaire de Sherbrooke in Quebec. PARTICIPANTS: Patients 50 years of age and older who underwent a knee MRI in 2009. MAIN OUTCOME MEASURES: The main outcome measure was an invasive procedure in the same knee that underwent an MRI. Medical charts were reviewed up to 2014 for patient characteristics, MRI indication, ordering physician specialty, radiography before MRI, MRI findings, and clinical procedures resulting from the MRI. RESULTS: The patients' mean (SD) age was 60.6 (7.5) years. The main MRI indications were meniscopathy (148 [68.8%]) and chronic pain (92 [42.8%]). The main MRI findings were osteoarthritis (OA) (185 [86.0%]) and meniscal lesions (170 [79.1%]). Only 82 (38.1%) patients had a plain radiograph in the 24 months preceding the MRI, usually without a standing anteroposterior view. Findings on pre-MRI radiography (n = 201) demonstrated OA in 144 (71.6%) patients. Overall, 87 (40.5%) patients were seen by an orthopedic surgeon and 27 (31.0%) of these patients underwent an invasive intervention. Among the 81 patients with moderate to severe OA on MRI, 36 (44.4%) had radiographic evidence of moderate to severe OA and only 3 (3.7%) underwent arthroscopic meniscectomy. CONCLUSION: Our study reproduces the known association between OA and degenerative meniscal changes in older patients. We have found a surprising underuse of the standing anteroposterior view on radiography. Most patients in our cohort could have been appropriately diagnosed and treated based on such radiographic information, as demonstrated by pre-MRI findings, thus avoiding the MRI and subsequent evaluation by an orthopedic surgeon. Meniscectomy was rarely performed, particularly in patients with advanced OA. Educational and pragmatic measures must be emphasized to encourage the use of radiography and to limit the inappropriate use of MRI, a costly technique.

A Heart Stopping Case of the Bezold-Jarisch Reflex.

The Bezold-Jarisch reflex is a parasympathetic reflex induced by intense mechanical stimulation of the ventricular myocytes. Exceptionally, cases have been described in patients receiving dobutamine infusion during a stress echocardiography. All were healthy middle-aged women and recovered without sequelae. A healthy 60-year-old woman suffered two 5.9-second episodes of asystole during her 20 mcg/kg/min infusion of dobutamine. Recovery was quick and without sequelae. Echocardiography and coronary angiography were both normal. In conclusion, this is the fourth documented case of a severe Bezold-Jarisch reflex causing asystole during dobutamine infusion. Diagnosis can only be made after excluding all other possible diagnoses, most importantly ischemia. This serves as a reminder of the importance of close monitoring during dobutamine infusion.

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) presenting as diffuse myositis.

BACKGROUND: Eosinophilic granulomatosis with polyangiitis is a complex multisystemic syndrome with heterogeneous presentation. Most often, there is a clinical history of asthma or other atopic conditions, and current presentation generally includes signs of cutaneous or pulmonary involvement. Very few reports described myalgia or weakness as the chief complaint. Of these, only a few included muscle biopsy evaluation and none showed convincing evidence of primary myositis. We believe this report is the first to demonstrate true myositis in the setting of early eosinophilic granulomatosis with polyangiitis. CASE PRESENTATION: This report describes a 74 year old Caucasian man, with no known allergies, presenting severe myalgia, muscle weakness, jaw claudication, and fever. Blood work showed marked eosinophilia and high creatine kinase levels. Biceps brachialis muscle biopsy revealed eosinophilic necrotizing vasculitis and true myositis with myophagocytosis of non-necrotic fibers and strong sarcolemmal MHC-1 overexpression by immunohistochemistry. This patient was successfully treated with prednisone and azathioprine. CONCLUSION: Our finding of true myositis in a case of eosinophilic granulomatosis with polyangiitis suggests that primary auto-immunity against muscle fibers, distinct from the secondary effects of vasculitis, can occur in this entity and may represent an overlap syndrome. Early recognition of eosinophilic granulomatosis with polyangiitis in patients presenting with myositis may provide an opportunity to treat the vasculitis before onset of severe multisystemic disease. We recommend the use of muscle biopsy with immunohistochemistry for MHC-1 to confirm the diagnosis of myositis in the setting of eosinophilic granulomatosis with polyangiitis.