Aseptic Meningitis Linked to Borrelia afzelii Seroconversion in Northeastern Greece: An Emerging Infectious Disease Contested in the Region.

Borreliosis (Lyme disease) is a zoonosis, mediated to humans and small mammals through specific vectors (ticks), with increasing global incidence. It is associated with a variety of clinical manifestations and can, if not promptly recognized and left untreated, lead to significant disability. In Europe, the main Borrelia species causing disease in humans are Borrelia burgdorferi s.s., Borrelia afzelii, Borrelia garinii, and Borrelia spielmanii. The Ixodes ricinus tick is their principal vector. Although Lyme disease is considered endemic in the Balkan region and Turkey, and all three main Lyme pathogens have been detected in ticks collected in these countries, autochthonous Lyme disease remains controversial in Greece. We report a case of aseptic meningitis associated with antibody seroconversion against Borrelia afzelii in a young female patient from the prefecture of Thasos without any relevant travel history. The patient presented with fever and severe headache, and the cerebrospinal fluid examination showed lymphocytic pleocytosis. Serum analysis was positive for specific IgG antibodies against Borrelia afzelii. In the absence of typical erythema migrans, serological evidence of infection is required for diagnosis. Although atypical in terms of clinical presentation, the seasonality and geographical location of potential disease transmission in the reported patient should raise awareness among clinicians for a still controversial and potentially underreported emerging infectious disease in Greece.

Pneumocephalus; a rare cause of coma.

We report the case of an 84-years old female patient who developed cerebral air embolism in association with the indwelling hemodialysis central venous catheter. Pneumocephalus, even though rare, should be included in the differential diagnosis of acute manifestation of neurologic deficits, especially in association with central venous access, surgical interventions or trauma, and requests prompt management. Brain computed tomography scanning remains the investigation of choice.

Anaerobic Spondylodiscitis caused by Parvimonas Micra in a Rheumatoid Arthritis Patient: Case Report and Review of the Literature.

We report the rare case of Parvimonas micra bacteraemia and secondary spondylodiscitis probably triggered by tooth injury in a rheumatoid arthritis patient. Anaerobic bacteria associated spondylodiscitis may evade diagnosis due to atypical clinical presentation usually lacking fever, and the difficulties related to microbiological characterisation of the pathogen. Even though anaerobic spinal infections may constitute <3% of the total, clinical suspicion should remain high, especially in the case of positive history for pre-existing oral cavity or gastrointestinal/gynaecological tract infections.

Boosting the Limited Use of Mineralocorticoid Receptor Antagonists Through New Agents for Hyperkalemia.

BACKGROUND: Hyperkalemia is an important clinical problem that is associated with significant lifethreatening complications. Several conditions are associated with increased risk for hyperkalemia such as chronic kidney disease, diabetes mellitus, heart failure, and the use of renin-angiotensin-aldosterone system (RAAS) inhibitors. OBJECTIVE: The purpose of this review is to present and critically discuss treatment options for the management of hyperkalemia. METHOD: A comprehensive review of the literature was performed to identify studies assessing the drug-induced management of hyperkalemia. RESULTS: The management of chronic hyperkalemia seems to be challenging and includes a variety of traditional interventions, such as restriction in the intake of the dietary potassium, loop diuretics or sodium polystyrene sulfonate. In the last few years, several new agents have emerged as promising options to reduce potassium levels in hyperkalemic patients. Patiromer and sodium zirconium cyclosilicate 9 (ZS-9) have been examined in hyperkalemic patients and were found to be efficient and safe. Importantly, the efficacy of these novel drugs might allow the continuation of the use of RAAS inhibitors, morbidity- and mortality-wise beneficial class of drugs in the setting of chronic kidney disease and heart failure. CONCLUSION: Data support that the recently emerged patiromer and ZS-9 offer significant hyperkalemia-related benefits. Larger trials are needed to unveil the impact of these drugs in other patients' subpopulations, as well.

A Rare Case of Disseminated Pyogenic Gonococcal Infection in an Immunocompetent Woman.

We present a case of previously healthy, immunocompetent, 41-year-old woman who developed systemic inflammatory response syndrome secondary to Neisseria gonorrhoeae bacteremia. Clinical course was complicated by the simultaneous formation of multiple muscular abscesses, epidural abscess, and septic spondylodiscitis. The patient responded well to prolonged ceftriaxone treatment and was released 10 weeks after initial admission. Spinal lesions and/or pyomyositis individually constitute rare complications of disseminated gonococcal infection. This case, combining both manifestations, is to our knowledge unique. Apropos, diversity of the clinical presentation, and therapeutic challenges for this historical disease are discussed for the practicing physician.

Response to rituximab and timeframe to relapse in rheumatoid arthritis patients: association with B-cell markers.

OBJECTIVE: Rituximab is used to deplete B cells and control disease activity, mainly in patients with rheumatoid arthritis (RA) who have not responded to anti-tumor necrosis factor (TNF) therapy. Response rates and time to relapse vary significantly among treated individuals. The objective of this study was to monitor the response of seropositive and seronegative RA patients to rituximab and correlate relapse with B-cell markers in the two groups. METHODS: Seventeen RA patients (eight seropositive for rheumatoid factor [RF+] and nine seronegative [RF-]) were treated with two cycles of rituximab. After treatment, all patients were re-evaluated at the outpatient clinic, and rituximab was readministered when disease relapse was confirmed by clinical-laboratory measures (Disease Activity Score [DAS]-28). CD20+ cells and CD20 receptor expression levels were estimated at initiation, relapse, and re-evaluation timepoints, and were compared between the two groups. RESULTS: Seropositive patients responded favorably to treatment compared with the seronegative group. The mean time to relapse was 337.5 +/- 127.0 days for the RF+ patients versus 233.3 +/- 59.6 days for the RF- patients (p = 0.043), despite more aggressive concomitant treatment in the seronegative group. The DAS28 decrease 3 months after treatment was 1.695 +/- 1.076 in seropositive patients versus 0.94 +/- 1.62 in seronegative patients. At relapse, CD20 receptor expression (molecules/cell) was higher in RF+ patients than in their RF- counterparts, despite a significantly lower percentage of CD20+ cells. CONCLUSION: Rituximab treatment is efficient in both seropositive and seronegative RA. However, seropositive RA patients tend to respond favorably compared with seronegative patients. The differential CD20 receptor expression in the two groups at relapse potentially suggests a different pathogenetic mechanism of relapse and merits further investigation.