Bibrachial amyotrophy and ventral spinal cyst associated with myelomalacia and intracranial hypertension.

It has been recently recognised that patients with ventral intraspinal fluid collections secondary to cerebrospinal fluid leaks can present with bibrachial amyotrophy or mimic Hirayama disease. Here we present two further patients that expand the clinical spectrum of this disorder to include association with myelomalacia and intracranial hypertension.

A retrospective review of acute encephalitis in adults in Auckland over a five-year period (2005-2009).

We conducted a retrospective audit of the outcomes of patients 15 years of age and older from the greater Auckland region who had a diagnosis of encephalitis over a five-year period. Patients were identified via a database search of all patients who had a cerebrospinal fluid (CSF) viral polymerase chain reaction (PCR) panel requested between 2005 and 2009. All CSF viral PCR were performed at one laboratory. This test was used as a default marker for patients who may have had encephalitis. There were 37 patients who met our definition of encephalitis during the study. Their ages ranged from 15 to 88 years (median 51 years), and 59% were female. There was an admission rate of 7.4 admissions per year or an annual incidence of approximately 0.5 cases per 100,000. An infective cause was found in 10 patients (27%): varicella zoster in five patients (14%), herpes simplex in four (11%) and enterovirus in one patient (3%). An autoimmune paraneoplastic encephalitis was felt most likely in three patients (8%); a paraneoplastic antibody screen was performed in two of these three but was negative in both. The cause of encephalitis was not identified in the other 24 patients (65%). There were five deaths (in-hospital mortality rate 14%). Encephalitis is an uncommon but important disease, because of the significant mortality. The cause of encephalitis remained undetermined in two-thirds of patients.

Rituximab-induced interstitial lung disease in a patient with immune thrombocytopenia purpura.

We report the case of an 84-year-old man with refractory immune thrombocytopenia purpura (ITP) who was treated with rituximab and subsequently developed severe interstitial lung disease. There has been increasing use of rituximab in the treatment of ITP with success rates of up to 62% in adult patients with recurrent ITP. Interstitial lung disease is a rare but recognised complication of rituximab but has been rarely reported in the setting of ITP.

A guide to anticoagulation and endocarditis prophylaxis during cutaneous surgery.

Management of perioperative antiplatelet/anticoagulation drugs and appropriate antibiotic prophylaxis for endocarditis are two controversial issues in the safe practice of cutaneous surgery. This article highlights the current best practice based on a literature review on these topics. Antiplatelet agents should be continued perioperatively whenever clinically possible, and discontinued only after consultation with the patient's cardiologist. The exception to this is primary cardiovascular disease, when antiplatelet drugs should be stopped for 1 week before surgery. Warfarin can be continued perioperatively when the international normalised ratio is controlled at < 3. The use of antibiotics in patients at risk of endocarditis has been recently reviewed by the National Institute of Health and Clinical Excellence (NICE), the American Heart Association, and the European Society of Cardiology. The advice has changed significantly over the past few years, and the routine use of antibiotics perioperatively should occur only when there is evidence of infection perioperatively at the site of surgery.

Polymorphisms in Toll-like receptor 4 and the systemic inflammatory response syndrome.

The systemic inflammatory response syndrome (SIRS) is a major cause of morbidity and mortality, and is thought to be due to an over-amplification of an inflammatory response. The Toll-like receptor 4 ( TLR4 ) Asp-299-->Gly polymorphism has been shown to reduce lipopolysaccharide responsiveness. We examined whether this TLR4 polymorphism is associated with severity of SIRS. A trend was found between the minor allele and mortality in SIRS (odds ratio of 4.3; P =0.076), suggesting a role for TLR4 signalling in the severity of SIRS.