Neuroborreliosis with Unusual Presentation: A Case Report.

Lyme disease is the most common vector-borne disease in the northern hemisphere. Neurological complications usually manifest in patients who do not receive treatment for Lyme disease. Neurological involvement may be early or late, depending on the duration of the symptoms. Early neuroborreliosis presents with symptoms such as headache and meningism; late neuroborreliosis can present with signs and symptoms of encephalopathy and stroke-like symptoms. The diagnosis is based on clinical manifestations and lumbar puncture finding. Treatment consists of intravenous antibiotics for a period of three to four weeks. Patients who receive early treatment usually have an excellent prognosis, with very few patients developing post-treatment Lyme disease syndrome. Here, we report an unusual case of Lyme disease with extremely high cerebrospinal fluid protein level and devastating neurological sequelae. The diagnosis of neuroborreliosis is based on neurological symptoms and lumbar puncture findings.

Use of Cardiac Troponin Testing in the Outpatient Setting.

OBJECTIVES: Cardiac troponin (cTn) measurement is useful for diagnosing myocardial infarction (MI), particularly in the inpatient setting. A growing body of literature suggests that cTn may be useful for evaluating chronic conditions in the outpatient environment; however, little is known regarding cTn ordering patterns in this setting. We sought to investigate patterns of care and outcomes for patients evaluated with cTn in the outpatient setting. We hypothesized that a majority of outpatient cTn orders would be for the purpose of diagnosing possible MI. METHODS: We analyzed 228 patients who had outpatient orders for standard-sensitivity troponin T assays placed at our institution between January 1, 2013 and December 18, 2015. Data were divided into two cohorts based on the intended utility of cTn measurement: orders placed to evaluate for possible MI versus orders placed for some other purpose. RESULTS: Of the 228 patients, 161 were evaluated for possible MI and 67 for other reasons. Risk factors (hypertension P = 0.32, diabetes mellitus P = 0.41, coronary disease P = 0.38, heart failure P = 0.098, and chronic kidney disease P = 0.70) were similar between the cohorts. In the suspected MI cohort, an electrocardiogram was obtained in only 77% of patients, and only 13.1% were sent to the emergency department (ED) for further evaluation. Within the suspected MI cohort, 10.5% (n = 17) had elevated cTn and the majority of these patients (n = 10) were not sent to the ED. CONCLUSIONS: The majority of outpatient cTn orders were intended to evaluate for MI, although electrocardiograms were frequently not ordered and few patients were sent for further ED evaluation. Providers should be encouraged to use cTn testing in a manner that minimizes the potential risk to patients with possible MI.

Recurrent blistering distal dactylitis due to Staphylococcus aureus in an immunocompetent elderly woman.

An 86-year-old woman presented with marked blistering of her left index fingertip and ulceration of the left middle fingertip, with a 2-year history of recurrent blistering and ulceration of her fingers bilaterally. She denied any preceding finger trauma, although she reported frequent gardening. She denied systemic symptoms. Her medical history was significant for a 2-year history of atrial fibrillation on carvedilol, amiodarone and apixaban, and she was a lifetime non-smoker. On admission, she had elevated inflammatory markers but unremarkable autoantibodies. Radiograph of the hand revealed diffuse soft tissue fullness and subtle irregularities at the tuft of the index finger, but all other investigations were unremarkable. The lesion was incised and drained, revealing blood-tinged purulent fluid. Wound biopsy revealed spongiosis with neutrophils, consistent with a diagnosis of blistering distal dactylitis.

Diffuse alveolar haemorrhage and Libman-Sacks endocarditis: a rare presentation of antiphospholipid syndrome.

A 26-year-old woman with a history of idiopathic thrombocytopaenic purpura and a 1-year history of blood-streaked sputum presented after a severe episode of haemoptysis with dyspnoea. Chest imaging revealed diffuse ground glass and bronchovascular nodules. Bronchoscopy revealed bilateral diffuse alveolar haemorrhage (DAH). Sputum and bronchoalveolar lavage studies were negative for infectious aetiologies. A transthoracic echocardiogram revealed Libman-Sacks endocarditis with severe mitral regurgitation and physical examination revealed retinal artery occlusion and Osler's nodes. The patient had an increased anticardiolipin Immunoglobulin IgG and anti-B2 glycoprotein IgG, suggesting antiphospholipid syndrome (APLS). The patient was then started on high-dose methylprednisolone and had an improvement in her dyspnoea and haemoptysis. She was also started on anticoagulation as treatment for Libman-Sacks endocarditis. APLS should be considered as a possible underlying aetiology for unusual presentations of DAH with concurrent Libman-Sacks endocarditis in non-intravenous drug users with existing autoimmune disorders.

Safety and efficacy of second-generation drug-eluting stents compared with bare-metal stents: An updated meta-analysis and regression of 9 randomized clinical trials.

The efficacy of second-generation drug-eluting stents (DES; eg, everolimus and zotarolimus) compared with bare-metal stents (BMS) in patients undergoing percutaneous coronary intervention was challenged recently by new evidence from large clinical trials. Thus, we aimed to conduct an updated systematic review and meta-analysis of randomized clinical trials (RCTs) evaluating the efficacy and safety of second-generation DES compared with BMS. Electronic databases were systematically searched for all RCTs comparing second-generation DES with BMS and reporting clinical outcomes. The primary efficacy outcome was major adverse cardiac events (MACE); the primary safety outcome was definite stent thrombosis. The DerSimonian and Laird method was used for estimation of summary risk ratios (RR). A total of 9 trials involving 17 682 patients were included in the final analysis. Compared with BMS, second-generation DES were associated with decreased incidence of MACE (RR: 0.78, 95% confidence interval [CI]: 0.69-0.88), driven by the decreased incidence of myocardial infarction (MI) (RR: 0.67, 95% CI: 0.48-0.95), target-lesion revascularization (RR: 0.47, 95% CI: 0.42-0.53), definite stent thrombosis (RR: 0.57, 95% CI: 0.41-0.78), and definite/probable stent thrombosis (RR: 0.54, 95% CI: 0.38-0.80). The incidence of all-cause mortality was similar between groups (RR: 0.94, 95% CI: 0.79-1.10). Meta-regression showed lower incidences of MI with DES implantation in elderly and diabetic patients (P = 0.026 and P < 0.0001, respectively). Compared with BMS, second-generation DES appear to be associated with a lower incidence of MACE, mainly driven by lower rates of target-lesion revascularization, MI, and stent thrombosis. However, all-cause mortality appears similar between groups.

A dirty cause of vancomycin-mediated Henoch-Schonlein purpura: oxygen tubing is not a foley.

A 59-year-old male presented with methicillin-resistantStaphylococcus aureus bacteraemia from a prostatic abscess and was treated with vancomycin. Two weeks into his treatment course, he developed severe joint pains, abdominal pain with bloody, mucinous stools and a diffuse palpable purpuric rash on his extremities. Biopsy of the rash showed IgA immune-complex deposition consistent with Henoch-Schönlein purpura. After treatment with glucocorticoids, his symptoms resolved completely. Vancomycin is an extremely commonly used antibiotic with certain well-known adverse effects. Henoch-Schönlein purpura, a vasculitis involving abdominal pain, arthralgias and palpable purpura, is a much less common side effect, as seen in this patient. Given that vancomycin is widely used internationally, clinicians should be aware of the risks entailed by its use.