[Wasp and bee stings with serious consequences]. / Wespen- en bijensteken met ernstige gevolgen.

Wasp and bee stings can lead to allergic reactions, anaphylaxis, Kounis syndrome, toxicity, organ failure and, in rare cases, cardiac arrest. In the Netherlands, fatal complications as a result of wasp or bee stings are rare; here we describe three recent severe cases. We diagnosed two patients with anaphylactic shock due to multiple wasp stings, resulting in cardiac arrest and death. Taking the number of stings (> 100) in one of these cases into account, a differential diagnostic consideration was 'exogenic toxic shock'. Considering the severe reaction with fatal outcome in both patients we cannot rule out the existence of indolent mastocytosis. The third patient developed grade 1 anaphylaxis and severe facial swelling, but survived. In this article we describe the pathophysiological background, treatment, diagnostics and desensitisation therapy.

A rare bloodstream infection: Bacillus mycoides.

A 65-year-old male was admitted to the Intensive Care Unit after being resuscitated because of a hypoxic cardiac arrest caused by influenza. Blood cultures taken at time of admission surprisingly grew Bacillus mycoides, a spore-producing apathogenic agriculture bacterium. We collected culture samples at his barge. Although we did not culture Bacillus mycoides, we did find multiple other Bacillus species. We hypothesised that our patient was colonised from the freights of his barge, and bloodstream infection occurred during resuscitation with either the bacterium itself or its spores. To our knowledge, this is the first report on bloodstream infection with Bacillus mycoides in a human patient.

Legionella longbeachae; don't miss it!

We here report on two immunocompetent patients admitted to our hospital within 3 weeks' time, both suffering from pneumonia caused by Legionella longbeachae (L. longbeachae). The pathogen was identified in broncho-alveolar lavage (BAL) liquid by Polymerase Chain Reaction (PCR), whereas sputum cultures remained negative. This organism is worldwide still relatively unknown and consequently underdiagnosed. However, with an increasing number of confirmed infections in Europe and more specifically in the Netherlands, early awareness and diagnostic measurements are indicated. As routine laboratory techniques like the urine antigen test do not detect L. longbeachae, we advocate early use of specific tests for non-pneumophila Legionella species such as PCR. Furthermore, we advocate the start of empirical antibiotic therapy (i.e. ciprofloxacin) and continuation in suspected cases.

A massive binary black-hole system in OJ 287 and a test of general relativity.

Tests of Einstein's general theory of relativity have mostly been carried out in weak gravitational fields where the space-time curvature effects are first-order deviations from Newton's theory. Binary pulsars provide a means of probing the strong gravitational field around a neutron star, but strong-field effects may be best tested in systems containing black holes. Here we report such a test in a close binary system of two candidate black holes in the quasar OJ 287. This quasar shows quasi-periodic optical outbursts at 12-year intervals, with two outburst peaks per interval. The latest outburst occurred in September 2007, within a day of the time predicted by the binary black-hole model and general relativity. The observations confirm the binary nature of the system and also provide evidence for the loss of orbital energy in agreement (within 10 per cent) with the emission of gravitational waves from the system. In the absence of gravitational wave emission the outburst would have happened 20 days later.

Thalidomide as treatment for digestive tract angiodysplasias.

An 80-year-old man with von Willebrand's disease was admitted with severe melaena. Despite suppletion with von Willebrand concentrate he continued to be dependent on blood transfusions. Endoscopic examination did not show a bleeding focus. Video capsule endoscopy showed active bleeding from angiodysplasias in the proximal section of the small intestine. Ultimately, treatment with thalidomide was initiated at a dose of 100 mg/day. Soon after starting treatment his stools became normal and his haemoglobin level stabilised. No bleeding problems occurred for 11 months, after which the thalidomide treatment was stopped because of the potential side effects. Two months later he again developed melaena and treatment with thalidomide was restarted with a successful outcome. Trying to lower the dose to 50 mg resulted in rebleeding after three months with stabilisation after increasing the dose to 100 mg again. Monotherapy with thalidomide improves the clinical picture but may not be sufficient in the long term. Additional therapy, such as argon plasma coagulation or the use of the novel drug lenalidomide, might be necessary.