Case Report: Thrombotic-Thrombocytopenic Purpura Following Ipilimumab and Nivolumab Combination Immunotherapy for Metastatic Melanoma.

A man in his early 50s presented with small bowel obstruction, requiring emergency laparoscopic small bowel resection for the metastatic melanoma of the jejunum with no identifiable primary lesion. One week after his first treatment with ipilimumab and nivolumab, he presented with diffuse abdominal pain, constipation, and fatigue. A computerized tomography scan did not identify a cause for his symptoms. This was rapidly followed by thrombocytopenia on day 11 and then anemia. He commenced intravenous corticosteroids for a suspected diagnosis of immune-related thrombocytopenia. On day 15, a generalized onset motor seizure occurred, and despite plasmapheresis later that day, the patient died from fatal immune-related thrombotic thrombocytopenic purpura (TTP). This was confirmed with suppressed ADAMTS13 (<5%) testing on day 14. Immune-related TTP is a rare and, in this case, fatal immune- related adverse event. Further studies are required to identify additional immunosuppressive management for immune-related TTP.

Characterisation of Exiguobacterium aurantiacum isolates from blood cultures of six patients.

Exiguobacterium spp. are alkaliphilic, halotolerant, non-spore-forming Gram-positive bacilli, hitherto uncharacterized from human infections. Six isolates of Exiguobacterium aurantiacum were obtained from patients with bacteraemia, three of whom had myeloma. All isolates formed orange-yellow pigmented colonies on blood agar, were catalase- and DNase-positive, and grew on nutrient agar at pH 10 and in the presence of NaCl 6% w/v. The six isolates were susceptible to all antimicrobial agents tested and were uniform in their fatty acid and mass spectrum profiles.

Disseminated Aspergillus terreus infection arising from cutaneous inoculation treated with caspofungin.

A case of disseminated Aspergillus terreus infection in a patient with prolonged neutropenia after stem cell transplant for myeloma is reported. The isolate was resistant to amphotericin B in vitro, and the patient was successfully managed with surgical debridement and the recently licensed antifungal agent caspofungin. There are many challenges associated with treating invasive aspergillosis, particularly that due to A. terreus, and the early use of caspofungin should be considered.

Documentation of positive blood culture results in a London teaching hospital.

OBJECTIVES: Our current practice is that initial (day 1) positive blood culture results are communicated to clinical teams; the task of recording those results in the notes is left to the clinical team. Microbiological information may be of crucial importance to an on-call doctor asked to review an unwell patient. We therefore sought to establish the extent to which day 1 positive blood culture information is available in patients' notes and its accuracy. METHODS: There were 51 positive blood cultures over a 14-day period. Patient notes of 39 of these were available for examination for evidence of the day 1 culture report, the accuracy of that report and evidence of clinical interpretation. RESULTS: The proportion of notes with a record was disappointingly low (54%), although the record was almost always accurate. Results reported at the weekend were as likely to be recorded in the notes as those given during the week. CONCLUSION: On-call doctors, not previously acquainted with a patient, will find that important information about day 1 positive blood culture results is not available to them in patient notes in around half of all cases. This adds weight to the view that medical microbiologists should give greater priority to ward visits and documentation of significant results, thus ensuring continuity of care from the laboratory bench to the bedside.

A study of the incidence of accidents occurring during an Arctic expedition: another important aspect of travel medicine?

The number of expeditioners and independent adventure travelers to remote and physically demanding areas is increasing. Recent evidence suggests that trauma and accidents (resulting mainly from road traffic accidents and drowning) are the primary cause of mortality in travelers rather than infectious diseases.1,2 The risks and potential hazards faced on an expedition are likely to be different from those encountered by other travelers. An extensive literature search revealed little data concerning the incidence and nature of accidents on expeditions, or concerning the young adventure traveler. The objective of this study was to determine the frequency and type of accidents that occurred on a 6-week summer arctic expedition, undertaken by "young explorers" and their leaders. This information will be valuable in order to identify potential risks as part of the pretravel risk assessment, and consequently improve the medical briefing and training of expeditioners and adventure travelers.

Stress long-axis function in coronary artery spasm.

In a patient with prior myocardial infarction who had complained of frequent angina repeat arteriograms proved normal coronary arteries. Both ECG exercise testing and thallium scanning excluded ischemia. Resting echocardiogram showed increased distal septal and right ventricular apical myocardial echo intensity. Dobutamine stress echo demonstrated right ventricular and posteroseptal abnormalities consistent with ischemia. Repeat angiogram with ergonovine confirmed distal right coronary spasm.

Clinical, molecular and epidemiological description of a cluster of community-associated methicillin-resistant Staphylococcus aureus isolates from injecting drug users with bacteraemia.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is an increasing problem, predominantly in previously healthy individuals including notable risk groups such as the homeless, those who play close-contact sports, military personnel, men who have sex with men (MSM) and injecting drug users (IDUs). Over a 5-month period, four IDUs were admitted to Addenbrooke's Hospital, Cambridge, UK, with MRSA bacteraemia. All four patients presented with complex clinical features, with more than one focus of infection, and were linked epidemiologically. The atypical antibiogram of the MRSA isolates (ciprofloxacin-susceptible) prompted further characterization, both phenotypically (antibiotic resistance typing; phage typing) and genotypically (detection of toxin genes by PCR; pulsed-field gel electrophoresis (PFGE); Staphylococcal chromosome cassette (SCC) mec typing; multi-locus sequence typing (MLST)). All four isolates had similar antibiograms, were Panton-Valentine Leucocidin (PVL) toxin gene-negative, harboured SCCmec type IV and were closely related as shown by phage typing and PFGE. These isolates were representatives of a community-associated clone, ST1-MRSA-IV, known to be circulating in IDUs in the UK since 2001. This paper presents a detailed description of the clinical, microbiological and epidemiological features of a series of CA-MRSA bacteraemias in IDUs in the UK.

E-mail consultations in international health.

We describe an e-mail health-consultation service for overseas volunteers that has been in operation for 25 months. The scheme is accessed for diverse medical concerns and is efficient and highly valued.

Contribution of cranial nerve ganglia to innervation of the walls of the rat external acoustic meatus.

The retrograde neuronal tracer, fluorogold, was used to determine the relative contributions of neurons in selected cranial nerve ganglia to the somatosensory innervation of the external acoustic meatus in the rat. Frozen sections from the trigeminal (semilunar), facial (geniculate), glossopharyngeal (superior petrosal) and vagal (jugular) nerve ganglia were examined by epifluoresence microscopy 10 to 14 days after application of the tracer dye fluorogold to the superior, inferior, anterior and posterior walls of the external acoustic meatus. The anterior wall of the canal makes a large contribution to the trigeminal ganglion and a lesser contribution to the other 3 ganglia. The trigeminal ganglion is also a major recipient from the posterior wall with smaller contributions from that wall to the geniculate and vagal ganglia. The superior wall projects a relatively constant supply to all 4 ganglia while the inferior wall primarily relays to the trigeminal and geniculate ganglia sending smaller contributions to the vagal and glossopharyngeal ganglia. In conclusion, neurons in these 4 cranial nerve ganglia contribute an overlapping supply to the 4 walls of the external ear meatus, and there is no evidence of a preferential distribution of nerve supply from one particular ganglion or nerve to specific walls of the external acoustic meatus.