Non-contiguous multifocal vertebral osteomyelitis caused by Serratia marcescens.

Serratia marcescens is a common nosocomial infection but a rare cause of osteomyelitis and more so of vertebral osteomyelitis. Vertebral osteomyelitis caused by this organism has been reported in few studies. We report a case of S. marcescens vertebral discitis and osteomyelitis affecting multiple non-contiguous vertebras. Although Staphylococcus aureus is the most common cause of vertebral osteomyelitis, rare causes, such as S. marcescens, need to be considered, especially when risk factors such as intravenous heroin use, post-spinal surgery and immunosuppression are present. Therefore, blood culture and where necessary biopsy of the infected region should be undertaken to establish the causative organism and determine appropriate antibiotic susceptibility. Prompt diagnosis of S. marcescens vertebral osteomyelitis followed by the appropriate treatment can achieve successful outcomes.

Diuretic-associated electrolyte disorders in the elderly: risk factors, impact, management and prevention.

Electrolyte and acid-base disorders are commonly encountered adverse effects of various diuretic agents, which are associated with considerable morbidity and mortality especially in elderly patients. Diuretic use is associated with hyponatraemia, hypernatraemia, hypokalaemia, hyperkalaemia, hyperuricaemia and alterations in magnesium, calcium, phosphate and acid-base homeostasis. Clinical studies have provided important data on the relative frequency and risk factors for these diuretic-associated electrolyte and acid-base disorders. Old age is one of the most recognized risk factors for diuretic-associated electrolyte and acid-base disorders. Hyponatraemia and hypokalaemia are the most common electrolyte abnormalities found among the elderly population taking diuretics. Both conditions are associated with short and long-term morbidity as well as mortality. This article presents an overview of the literature on diuretic-associated electrolyte disorders and suggested risk factors for their development especially in elderly patients when evidence is available. The impact of these electrolyte disorders on patients will be discussed. Strategies to prevent adverse outcomes related to these disorders should involve careful consideration of risk factors as well as ongoing clinical and laboratory evaluations in the course of using these diuretics.

Medication prescription among elderly patients admitted through an acute assessment unit.

AIM: This study assessed medication use patterns and polypharmacy in patients who were admitted through an acute assessment unit (AAU) and stratified results according to patient age. This study also examined risk factors associated with polypharmacy and consequences of polypharmacy, namely prescription writing errors, drug-drug interaction and geriatric syndrome. METHODS: The medication charts and admission notes of 200 consecutive patients admitted through the AAU over a period of 1 month were retrospectively reviewed. Data were collected on patients' demographics, comorbidities, types and number of medications, hospital length of stay and reason(s) for presentation. Potentially harmful prescription errors or errors necessitating intervention were also recorded, as were any potential adverse drug-drug interactions. RESULTS: Medications for the treatment of disorders of the cardiovascular (46% of total patients) and nervous systems (30%) predominated. Of the 200 patients reviewed, 158 were aged ≥ 65 years and their mean serum creatinine was higher than those aged < 65 years (100.9 ± 54.0 vs. 79.9 ± 45.9 µmol/L, P = 0.01), 81% were taking five or more concurrent regular medications at the time of admission. Of all 200 patients, 28% suffered renal impairment, defined as creatinine > 100 µmol/L for women and > 120 µmol/L for men. The presence of more than two comorbidities (odds ratio (OR) 6.80; 95% confidence interval (CI) 2.89-16.00; P < 0.001) and age (OR 2.91; 95% CI 1.24-6.80; P = 0.01), were factors associated with polypharmacy. Excessive polypharmacy was associated with an increased risk of prescription errors that could cause temporary harm or required intervention (OR 5.23; 95% CI 1.39, 19.69; P = 0.009) but was not associated with a prolonged length of stay. CONCLUSIONS: This study showed that polypharmacy and renal impairment are prevalent amongst elderly patients admitted through an AAU. Polypharmacy in the elderly is attributable to greater comorbidities and is associated with an increased risk of adverse consequences. To avoid inappropriate medication use and improve the quality of prescription among those with polypharmacy, careful review of elderly patients' drugs is needed while they are in the AAU.

Streptococcus dysgalactiae endocarditis presenting as acute endophthalmitis.

Endogenous endophthalmitis is a rare ocular infection affecting the vitreous and/or aqueous humours. It is associated with poor visual prognosis and its commonest endogenous aetiology is infective endocarditis. The causative organisms of endogenous endophthalmitis complicating endocarditis are mainly Group A or B streptococci. The identification of Group C and G streptococci such as Streptococcus dysgalactiae is comparatively uncommon and has only been reported in a few case reports or series. We therefore report a case of infective endocarditis caused by Streptococcus dysgalactiae first presenting with endogenous endophthalmitis, the most likely source being osteomyelitis of both feet in a patient with type I diabetes. The patient was treated with a course of intravenous benzylpenicillin, intravitreal antibiotics, bilateral below knee amputations and mitral valve replacement. She survived all surgical procedures and regained partial visual acuity in the affected eye.

Severe hyponatremia and other electrolyte disturbances associated with indapamide.

PURPOSE: The aim of this study is to evaluate patients' demographics, patterns of presentation and outcomes of admissions with severe hyponatremia and other electrolyte disturbances that are related to indapamide. METHODS: Patients with severe indapamide-related hyponatremia (defined as serum sodium <125 mmol/L) admitted to the Department of General Medicine of a tertiary teaching hospital between 1 July 2006 and 30 June 2009 were evaluated in this study. Patients' characteristics, clinical features of their presentation and other electrolyte disturbances were analyzed retrospectively. RESULTS: Eleven patients were admitted with severe hyponatremia and other electrolyte disturbances associated with indapamide use. All patients were female and elderly (age: 81.7 ± 5.8 years). Their mean weight was 59.0 ± 8.8 kg. Indapamide sustained release (SR) 1.5 mg daily was taken by eight of eleven patients and the others took indapamide 2.5 mg in combination with perindopril. The mean serum sodium concentration on presentation was 110.9 ± 5.9 mmol/L and was associated with findings of hypokalemia in ten patients and hypomagnesemia in eight patients. All patients presented predominantly with neurological manifestations, delirium (six patients) being the most common. Electrocardiographic changes were common (nine patients) including prolonged QT interval in six patients. All the patients' electrolyte abnormalities were corrected without any life-threatening complications. CONCLUSIONS: This study highlights that the use of indapamide is associated with severe hyponatremia and other electrolyte disturbances. Therefore clinicians should be aware of severe electrolyte disturbances arising from indapamide. New onset of neurological symptoms such as delirium and unsteady gait in the elderly taking indapamide should prompt evaluation of their electrolyte profile.

Bilateral renal inflammatory pseudotumour effectively treated with corticosteroid.

Inflammatory pseudotumour (IPT) is a rare disease of unknown cause that most commonly involves the lung but can occur in almost any site in the body. Occurrence in the kidneys is very rare and bilateral renal involvement even rarer. There are 34 previously reported cases in the English-language medical literature between 1966 and 2008. Herein we report a case of IPT infiltrating both kidneys. We have also reviewed the clinical features, radiological findings, treatment and outcome of renal IPT. Clinical features at presentation are commonly non-specific. Features on imaging are inadequate to make a diagnosis of IPT or to clearly distinguish it from malignancy. Consequently diagnosis has frequently been made after nephrectomy and on a few occasions with the aid of percutaneous or open biopsies. The majority of renal IPT (83%) have been treated with nephrectomy and those cases with bilateral IPT have received corticosteroids.

Proteus vertebral osteomyelitis.

Proteus organisms are rare causes of osteomyelitis. Vertebral osteomyelitis caused by this organism has only been reported in 21 cases over the last 75 years. Although Staphylococcus aureus is the most common cause of vertebral osteomyelitis, rare causes such as P. mirabilis may need to be considered in the context of recent urinary tract infection or urological surgery. Therefore biopsy should be undertaken to establish the causative organism and determine appropriate antibiotic susceptibility.