Cryptococcus neoformans var. grubii septic arthritis in an immunocompromised patient on haemodialysis with history of splenectomy and sarcoidosis.

A male adult in his mid-40s with end-stage renal disease (ESRD) on haemodialysis, with history of splenectomy and sarcoidosis, developed septic arthritis of the knee. Excision and drainage was performed and empiric antibiotics were initiated. Cultures were initially negative without clinical improvement. Eventually, the aerobic synovial fluid culture grew Cryptococcus neoformans (formerly Cryptococcus neoformans var. grubii). The patient was treated with liposomal amphotericin B and then switched to fluconazole until the infection resolved. This case highlights the less well-recognised association between cryptococcal arthritis and immunodeficiency states like ESRD, splenectomy and sarcoidosis.

Normal ESR, CRP and Platelet Count in Giant Cell Arteritis and Polymyalgia Rheumatica: A Diagnostic Conundrum.

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are both rheumatological diseases of the elderly with a strong association with each other and which rarely present with normal inflammatory markers. Here we present the case of a 61-year-old Caucasian woman who had typical symptoms of both diseases. At the time of presentation, her blood work showed normal inflammatory markers, but because of the high clinical suspicion for GCA, a temporal artery biopsy was done which was positive for giant cells and disruption of the internal elastic lamina. Our patient responded very well to treatment with oral steroids and steroid-sparing medication and was able to return to her normal life without experiencing any complications of the disease. By sharing our case, we aim to increase the awareness of medical personnel regarding the importance of focusing on the clinical presentation as well as the laboratory and pathological aspects of diagnosing GCA and PMR. LEARNING POINTS: Normal levels of inflammatory markers like C-reactive protein and the erythrocyte sedimentation rate do not rule out the diagnosis of giant cell arteritis (GCA).We aim to increase clinician recognition and awareness of other parameters, particularly the clinical presentation, that should be considered when diagnosing GCA or polymyalgia rheumatica.If the index of suspicion for the disease is high, it is crucial to start treatment as early as possible for better management and to avoid harmful complications.

Important reminder: nitrous oxide (N2O) as a cause of functional vitamin B12 deficiency.

A 32-year-old woman who misused multiple substances, including nitrous oxide (N2O), sought medical advice after she subacutely developed bilateral lower extremity weakness without a sensory level but with ataxia-her significant other developed similar symptoms with vitamin B12 deficiency due to N2O intake. Laboratory results revealed macrocytic anaemia despite normal B12 and folate levels, with serum markers pointing towards functional cobalamin deficiency. Spinal MRIs and cerebrospinal fluid analysis were unremarkable. Our patient was treated with vitamin B12 supplementation with an encouraging response.