Pericardial tamponade masquerading as septic shock.

A 53-year-old man with steroid dependent rheumatoid arthritis presented with fever and serous articular drainage. Oral antibiotics were initially prescribed. Subsequent hemodynamic instability was attributed to septic shock. Further evaluation revealed a pericardial effusion with tamponade. Pericardiocentesis of purulent fluid promptly corrected the hypotension. Proteus mirabilis was later isolated from both the infected joint and the pericardial fluid. This is the first report of combined Proteus mirabilis septic arthritis and purulent pericarditis. It documents the potential for atypical transmission of Gram-negative pathogens, to the pericardium, in patients with a high likelihood of preexisting pericardial disease. In immunocompromised patients, the typical signs and symptoms of pericarditis may be absent, and the clinical presentation of pericardial tamponade may be misinterpreted as one of septic shock. This case underscores the value of a careful physical examination and proper interpretation of ancillary studies. It further illustrates the importance of initial antibiotic selection and the need for definitive treatment of septic arthritis in immunocompromised patients.

Magnetic resonance imaging in the assessment of coronary artery disease.

Magnetic resonance imaging (MRI) is gaining importance in cardiology as the noninvasive test of choice for patients with a multitude of cardiovascular problems. Recently, cardiovascular MRI has emerged as an important noninvasive diagnostic modality in the assessment of coronary artery disease. Because of its superior spatial resolution, integration of qualitative and quantitative methodology, and excellent reproducibility, MRI has advantages over conventional noninvasive modalities currently used in the evaluation of coronary artery disease. This article reviews the rapidly expanding recent literature that has now established cardiovascular MRI as an ideal choice in the evaluation of myocardial ischemia (including dobutamine cine MRI and vasodilator perfusion MRI techniques). We further discuss the role of delayed contrast-enhanced MRI and low-dose dobutamine cine MRI for evaluation of myocardial viability. Comparisons with more established techniques, such as dobutamine stress echocardiography, single-photon emission computed tomography perfusion imaging, and positron emission tomography, are reviewed.

Evaluation and outcome of proteinuria in older and younger adults.

BACKGROUND: The spectrum of proteinuric renal disease in older adults remains incompletely defined. The purpose of the present study was to determine if differences exist in diagnostic approach, etiology, therapy, and outcome between older (> or = 60 years) and younger (<60 years) patients referred for evaluation of proteinuria. METHODS: We conducted a retrospective review of outpatient office charts in a 7-physician, hospital-based nephrology practice. RESULTS: We identified 69 patients with at least 1 subsequent follow-up assessment after reviewing approximately 500 sequential charts. Forty-five were younger (mean +/- SD age, 38 +/- 2 years), and 24 were older (69 +/- 1 years). The degree of proteinuria at presentation was similar (4.5 +/- 0.7 vs 3.9 +/- 0.6 g/d, older vs younger, p = NS), but older patients had higher creatinine levels (1.7 +/- 0.2 vs 1.2 +/- 0.07 mg/dl, p <.01), lower creatinine clearances (64 +/- 7 vs 111 +/- 7 ml/min., p <.05), and higher systolic blood pressure (164 +/- 8/88 +/- 2 vs 145 +/- 4/94 +/- 2 mm Hg, p <.01). Older patients were more likely to decline a renal biopsy (21% vs 7.6%, p <.01). The most common final renal diagnoses were immunoglobulin A nephropathy (31%), focal segmental glomerulosclerosis (24%), hypertension (13%), and membranous nephropathy (11%) in the younger patients, and membranous nephropathy (29%), hypertension (25%), diabetic nephropathy (17%), and minimal change disease (8%) in the older patients. Steroids were given to 17.7% of younger patients and 16.7% of older patients (p = NS). The percentage of patients with improvement, defined as a 50% reduction in proteinuria with stable or improved renal function, was similar among older and younger patients (33.3% vs 35.5%). However, older patients were more likely to develop progression of renal disease (33.3% vs 8.8%) and less likely to retain stable renal function (29.2% vs 53.3%). CONCLUSION: Significant differences exist in proteinuric renal disease between older and younger adults.