Splenic spread and hepatic encephalopathy in metastatic malignant melanoma.

An older adult patient was admitted with epigastric pain and vomiting and found to have an abdominal mass, increased cholestatic liver enzymes and markedly elevated serum lactate dehydrogenase (LDH). Imaging revealed extensive liver metastases of unknown primary but also an unusual splenic metastasis diagnosed by liver biopsy as malignant melanoma. The patient became lethargic and developed mental status changes associated with asterixis, abnormal EEG, and increased serum ammonia levels. All reversed with high-dose lactulose and had no alternative explanation other than an unusual hepatic encephalopathy secondary to portosystemic shunts bypassing the extensively metastatic liver.

Mind the caretaker: ED referrals of community-dwelling older adult patients by their primary caregivers are accurate.

BACKGROUND: ED referral of older adults on the initiative of their family or paid live-in caregiver is common but not previously studied. METHODS: ED-presenting community-dwelling patients ≥65 years were studied, emphasizing the referring agent, and correct (admitted or discharged +changed diagnosis/treatment) vs. incorrect referral (discharged, no change made). RESULTS: Of 448 consecutive patients (median age 83 years), 231 were referred by their primary physician (PCP) (73% admitted, 17% discharged +change). 117 ED referrals were initiated by their family (78% admitted, 6% discharged +change), and 100 by their paid caregiver (66% admitted, 21% discharged +change). Differences were non-significant, as was the distribution of main diagnoses. CONCLUSIONS: ED referral of older adults from the community by laymen who know the patient well (family or caregiver) is non-inferior to a referral by their PCP. ED physicians should regard non-physician ED presentations as seriously as a referral by a physician, pending confirmation in future studies.

Mediterranean spotted fever associated with leucocytoclastic vasculitis and acute pancraeatitis.

A young healthy gardener became febrile with abdominal pain, nausea, vomiting and diarrhoea followed by palpable purpura, mostly on the legs and buttocks with associated arthralgia. Dehydration, azotemia and hyponatraemia resolved with fluid replacement. Tests demonstrated acute pancreatitis, hepatitis, thrombocytopenia, microscopic haematuria and proteinuria. He improved with doxycycline, but bipedal pitting oedema and punctate rash involving the soles/hands appeared. Microbiological tests revealed positive IgM and IgG serology for rickettsiae spotted fever. Skin biopsy of the purpura confirmed leucocytoclastic vasculitis, positive for Rickettsiae conorii by PCR amplification. Palpable purpura is a rare important manifestation of Mediterranean spotted fever (MSF), due to either secondary leucocytoclastic vasculitis or associated Henoch-Schonlein purpura (HSP), which best explains the distribution of the rash, arthralgia, gastrointestinal symptoms, and microhaematuria not usually seen in R. conorii infections. Likewise, the patient's acute pancreatitis may be interpreted as a rare presentation of HSP or a seldom-encountered feature of MSF.