Atypical clinical presentation of meningococcal meningitis: a case report.

A young woman was examined in the Emergency Department for fever, pharyngitis and widespread petechial rash. Physical examination, including neurological evaluation, did not show any other abnormalities. Chest X-ray was negative. Blood exams showed leukocytosis and CPR 20 mg/dL (nv<0.5 mg/dL). On the basis of these results and petechial rash evidence, lumbar puncture was performed. CSF was opalescent; physico-chemical examination showed: total proteins 2.8 (nv 0.15-0.45), glucose 5 (nv 59-80), WBC 7600/µL (nv 0-4/ µL). In the hypothesis of meningococcal meningitis, antimicrobial therapy was started. Blood and cerebrospinal fluid cultures were positive for N. meningitidis. During the first hours the patient experienced hallucinations and mild psychomotor agitation, making a spontaneous recovery. A brain MRI showed minimal extra-axial inflammatory exudates. She was discharged after 10 days in good condition. We underline the need to consider meningococcal meningitis diagnosis when any suggestive symptom or sign is present, even in the absence of the classic meningitis triad, to obtain earlier diagnosis and an improved prognosis.

[New and old beta-blockers in the treatment of heart failure]. / Nuovi e vecchi beta-bloccanti nel trattamento dell'insufficienza cardiaca.

Controlled clinical trials, performed in more than 16,000 patients to date, have consistently shown the beneficial effects of long-term beta-blocker therapy in patients with chronic heart failure. However, it is not clear whether this represents a class effect or it is specific only to some agents. Beneficial effects on the prognosis of the patients with mild to moderate heart failure have been shown with metoprolol, bisoprolol, and carvedilol. However, these beta-blockers differ in their pharmacological characteristics. Metoprolol and bisoprolol are selective for beta 1-adrenergic receptors and are devoid of ancillary properties. Carvediol, at doses of 50 mg daily, blocks all beta 1-, beta 2-, and alpha 1- adrenergic receptors, and has associated antiproliferative and antioxidant activities. These differences cause a different acute hemodynamic response with a reduction in cardiac output and a tendency to a rise in pulmonary wedge pressure with selective agents and no change in cardiac output and a slight decrease in pulmonary pressures with carvedilol. Accordingly, when the therapy is started, the most frequent side effects are worsening heart failure with metoprolol and bisoprolol and hypotension and dizziness with carvedilol. It is still controversial whether these differences may also influence the long-term effects of therapy. Differently from selective beta-blockers, carvedilol does not upregulate beta 1-receptors, blocks all adrenergic receptors, decreases cardiac norepinephrine release, thus providing a more comprehensive blockade of the cardiac adrenergic drive. These properties have caused a larger increase in LV function and a lack of improvement in maximal exercise capacity with carvedilol, compared to selective beta-blockers. It is however, unclear whether these differences may also influence the patients' outcome.