Zebras Masquerading As Horses: A Case of Spinal Subarachnoid Haemorrhage.

A previously independent 83-year-old lady presents with acute confusion, decreased mobility, urinary retention, and constipation, having recently received a course of oral acyclovir for shingles. The patient was noted to have extensive bruising to her upper limbs, and blood tests showed raised inflammatory markers with low platelet count, although this remained above 75 × 109/L. Her confusion on a background of shingles raised the differential diagnosis of varicella-zoster virus (VZV) encephalitis. CT head and MRI brain showed no acute intracranial abnormality. Lumbar puncture yielded frankly haemorrhagic cerebrospinal fluid (CSF), but viral polymerase chain reaction (PCR) testing was negative for the varicella-zoster virus. She later developed further right shoulder pain and right lower limb weakness three days post-initial lumbar puncture. Repeat CT head was unremarkable. MRI spine showed extensive spinal subarachnoid haemorrhage, with possible cervical arteriovenous malformation and L5/S1 spinal nerve compression. The patient was managed conservatively with dexamethasone and inpatient physiotherapy support. She was discharged after a long hospital stay at a new mobility baseline requiring hoist transfers.

Fatal cardiac involvement complicating antisynthetase syndrome.

A 35-year-old Afro-Caribbean woman presented with dyspnoea, urticarial rash and myalgia 1 month after treatment for a community-acquired respiratory tract infection. Investigations revealed raised antisynthetase antibodies, lung fibrosis and an inflammatory myopathy. The patient was diagnosed with antisynthetase syndrome (ASS) and started on immunosuppressive medication. Despite treatment she died 4 weeks after presentation from a fulminant cardiomyopathy. ASS is a rare condition and is not typically associated with a cardiomyopathy. This case report intends to raise awareness that cardiomyopathy is a potentially fatal complication of ASS.

Screening for latent TB in patients with rheumatic disorders prior to biologic agents in a 'high-risk' TB population: comparison of two interferon gamma release assays.

Patients with rheumatic disorders treated with TNF inhibitors are at increased risk of developing TB. There is no 'gold-standard' for the diagnosis of latent TB prior to initiation of biologic agents. We report our own experience of comparing two interferon gamma release assays (IGRAs) in screening for latent TB in a 'high-risk' TB area in patients with rheumatic disorders. The study demonstrated good concordance between the two tests. We believe the additional cost of these assays is justified in high-risk populations prior to biologic agents, with 16% of the current study population with at least one positive IGRA assay.