Excruciating Low Back Pain After Strenuous Exertion: Beware of Lumbar Paraspinal Compartment Syndrome.

BACKGROUND: Low back pain is extremely common and usually a minor self-limiting condition. Rarely, however, it is a harbinger of serious medical illness. Paraspinal compartment syndrome is a rare condition, but its timely recognition is important to allow adequate treatment. CASE REPORT: A 16-year-old boy presented to the Emergency Department (ED) with severe low back pain, necessitating intravenous opioids. Laboratory results showed severe rhabdomyolysis. Magnetic resonance imaging of the lumbar spine showed diffuse edema and swelling in the paraspinal muscles. Aggressive fluid therapy was started but despite narcotic analgesia the pain persisted and creatine kinase (CK) levels increased. Compartment pressures of the erector spinae were found to be increased. The decision was made to proceed with bilateral paraspinal fasciotomies. Postoperatively, the patient noted immediate pain relief with rapid decrease of CK level. The patient is pain free and resumed running and swimming 3 months after admission in the ED. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although paraspinal compartment syndrome is a rare condition, its recognition is of paramount importance to allow adequate surgical treatment, preventing muscle necrosis. Although back pain most often has a benign course, a careful history and physical examination in patients presenting with low back pain allows determination of "red flags." Mandatory further diagnostic tests can identify underlying serious illness.

Characteristics of older adults admitted to the emergency department (ED) and their risk factors for ED readmission based on comprehensive geriatric assessment: a prospective cohort study.

BACKGROUND: Patients aged 75 years and older represent 12% of the overall emergency department (ED) population, and this proportion will increase over the next decades. Many of the discharged patients suffer an unplanned readmission in the immediate and midterm post-discharge period, suggesting under recognition of psychosocial, cognitive and medical problems. The aim of this study was to compare the characteristics of older patients admitted and discharged from the ED and to determine independent predictors for ED readmission 1 month and 3 months after ED discharge based on comprehensive geriatric assessment (CGA). METHODS: Cohort study in a Belgian university hospital. A CGA, including demographic and medical data (e.g. reason for admission, comorbidity, number of medications), functional (e.g. activities of daily living, falls), mental (i.e. cognition, dementia, delirium), and nutritional status, and pain, was performed in 442 ED patients aged 75 years or older. RESULTS: Patients discharged from the ED (n = 117, 26.5%) were significantly less dependent for ADL, mobility, shopping and finances compared with hospitalised patients. Hospitalised patients (n = 325, 73.5%) were significantly more at risk for having nutritional problems, had a higher comorbidity index, and a lower cognitive status compared with those discharged. Ninety-seven patients (82.9%) were discharged home from the ED. Of the latter, 18 (18.6%) and 28 patients (28.9%) suffered an ED readmission within 1 and 3 months, respectively. At one month post-discharge, nursing care at home, meals on wheels, and risk for depression; and at 3 months post-discharge previous hospitalisation in the last 3 months, physiotherapy and meals on wheels were found to be independent predictors for ED readmission, respectively. CONCLUSIONS: This study observed a geriatric risk profile in older adults at the ED and a high readmission rate of those discharged, and suggests the potential value of CGA in identifying older patients at high risk for ED readmission.

Canakinumab in Schnitzler syndrome.

OBJECTIVES: Daily injections of anakinra, an interleukin-1-receptor antagonist, have been reported to control effectively the symptoms and signs of Schnitzler syndrome, a rare acquired autoinflammatory disorder, presenting in adulthood by intermittent fever, urticarial rash, and paraproteinemia, usually IgM. Canakinumab, a fully human interleukin-1ß monoclonal antibody, approved for the cryoporin-associated periodic syndrome, may offer a practical advantage because its half-life of ∼28 days may allow less frequent dosing. The present trial was designed to test canakinumab in patients with Schnitzler syndrome. METHODS: A patient with Schnitzler syndrome was treated with canakinumab, 150 mg subcutaneously injection every 8 weeks for 6 consecutive months. Injections were resumed in case of a flare following discontinuation. RESULTS: Canakinumab induced a swift and sustained clinical response, with disappearance of fever and arthralgias, near abolishment of fatigue and rash, and substantial reduction of C-reactive protein levels. Interruption of canakinumab after four 8-weekly injections led to a flare 10 weeks after the last administration, which was countered as soon as canakinumab injections were resumed. The patient remained in complete remission. Canakinumab was well tolerated. No injection site reactions, other adverse events, or laboratory abnormalities were observed. CONCLUSIONS: Canakinumab has potential for the treatment of Schnitzler syndrome (ClinicalTrials.gov.number, NCT01245127).

Adult-onset Still's disease: still a diagnosis of exclusion. A nested case-control study in patients with fever of unknown origin.

OBJECTIVES: Several sets of criteria have been proposed to classify adult-onset Still's disease (AOSD), those of Yamaguchi being the most commonly used. The Yamaguchi criteria demand the exclusion of other conditions. A clinical scale, recently proposed by Crispin et al., but not yet validated, would allow a positive diagnosis of AOSD in a majority of patients, without the need of thorough diagnostic procedures. METHODS: From a database of 447 patients with classical fever of unknown origin (FUO), collected over a 10-year period (2000-2009) at a general internal medicine department of a university hospital, 22 patients with AOSD according to the Yamaguchi criteria were extracted and compared with 44 controls, matched to index year. Clinical and laboratory parameters were recorded. Sensitivity, specificity and accuracy of the Yamaguchi criteria and of the clinical score were assessed. RESULTS: Lower age, joint symptoms, rash, throat ache, neutrophilic leukocytosis, and elevated erythrocyte sedimentation rate were the principal characteristics supporting a diagnosis of AOSD in patients with FUO. Sensitivity, specificity, and accuracy of the Yamaguchi criteria were 95% or more. The clinical scale, while being specific (98%), lacked sensitivity (55%) and had lower accuracy (83%). CONCLUSIONS: In patients with FUO, the Yamaguchi criteria are a time honored and reliable guide to a diagnosis of AOSD. The clinical scale may serve to rule in, rather than to rule out, AOSD. In many patients, Still's disease is still a diagnosis of exclusion.

A simple tool to improve medication reconciliation at the emergency department.

BACKGROUND: Medication histories acquired upon admission are often incomplete. Using a standardized approach warrants more complete medication reconciliation, however, this is too time consuming to be performed. Other strategies guaranteeing complete medication histories should be explored. We developed a limited list of standardized questions and assessed its impact on completeness of medication histories. METHODS: This prospective study enrolled adults presenting to a tertiary care emergency department. In the control group, medication histories were conducted by physicians of general internal medicine conform standard care. In the intervention group, the physicians were obliged to use, besides the standard care, the 'limited questions list' for medication history acquisition. The clinical pharmacist re-obtained medication histories of the patients in both groups using a standardized approach. The primary outcome was the impact of the use of a 'limited questions list' on the frequency of drug omissions in medication histories. RESULTS: 260 consecutive patients were enrolled: 130 in the intervention group and 130 in the control group. There was a significant reduction of 49.3% in drug omissions in the intervention group. The omission rate per medication history was 1.1 for the control group, which was significantly lower (0.6) in the intervention group. Antithrombotics were most frequently forgotten in the control care group as opposed to dietary supplements in the intervention group. CONCLUSION: Drug omission rate in medication histories can be significantly reduced if a limited list of simple questions is used during anamnesis. Widespread use of this tool should be considered to be implemented.

Inflammation of unknown origin versus fever of unknown origin: two of a kind.

OBJECTIVES: A vast literature exists on fever of unknown origin (FUO), characterized by prolonged and perplexing fevers >38.3 degrees C. In contrast, no studies are available to guide the approach to inflammation of unknown origin (IUO), defined as prolonged and perplexing inflammation with temperatures <38.3 degrees C. We aimed to determine the diagnostic yield, the case-mix, and the outcome of patients with IUO, relative to patients with FUO. METHODS: We matched 57 patients with IUO to 57 patients with FUO of the same gender (54% male) and a similar age (median: 67 years). RESULTS: A diagnosis was established in 35 patients with IUO (61%) and in 33 patients with FUO (58%) (p=.70). The case-mix did not differ significantly (p=.43). Non-infectious inflammatory disorders were the dominant diagnostic category in the IUO group (16 patients), while in the FUO group, similar numbers of malignancies [10], infections [9], and non-infectious inflammatory diseases [9] were diagnosed. (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) scan contributed comparably to the diagnosis in both groups (in 18 of 50, 36%, patients with IUO and in 13 of 40, 33%, patients with FUO) (p=.83). In both groups, 7 patients (12%) died during an average follow-up of 1 year. CONCLUSION: Diagnostic yield, case-mix, contribution of FDG-PET scan and vital outcome were similar in patients with IUO and FUO. These data suggest that the 38.3 degrees C boundary may be arbitrary and that the diagnostic approaches used in FUO can be applied to IUO.

Endogenous carbon monoxide production: a rare and detrimental complication of extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a technique that can support gas-exchange and cardiac function in patients with acute respiratory or cardiac failure that is not responsive to conservative treatment. ECMO is a high-risk procedure in critically ill patients and both technical and patient-related complications frequently occur. We report on a patient with end-stage pulmonary fibrosis (histiocytosis x), in whom ECMO was used as bridge to urgent lung transplantation. Respiratory insufficiency necessitating ECMO therapy was due to spontaneous pneumothorax with bronchopleural fistula. Access was initially made by femoral veno-venous canulation. Due to right heart failure, access was switched to veno-arterial using the two existing canulae as efferent system and implanting a third canula on the femoral artery using a graft. Despite marked hemodynamic improvement after this intervention, high flow rates creating high premembrane pressures were required to ensure oxygenation. High levels of carboxyhemoglobin (COHb) occurred, most likely due to massive mechanical hemolysis in the ECMO circuit. This may have had detrimental effects by further complicating tissue oxygenation. We recommend that COHb should routinely be checked in ECMO patients.

Establishment of reference values for immunoglobulins in the cryoprecipitate.

Cryoglobulins are often estimated by determining cryocrit or total protein content in the cryoprecipitate, but these are only indirect measures. Direct quantification of immunoglobulins in combination with agarose gel electrophoresis, to appreciate the presence of other proteins in the cryoprecipitate, offers a more sensitive and specific tool for confirming the diagnosis of cryoglobulinemia. Using such strategy, we established reference values for immunoglobulins in cryoprecipitate in diseased controls and applied them to 214 consecutive patients. The 97.5th percentile for IgA, IgG and IgM in diseased controls was 2, 11 and 26 mg/L serum, respectively. The distribution of the 49 positive patients (23%) was 10% type I, 33% type IIa, 16% type IIb, and 41% type III. Complement C4 was decreased in 61% and 55% of the patients classified as type II and type III compared to 16% of the patients that were negative for cryoglobulins and 9% of the diseased controls.

Involuntary weight loss. Does a negative baseline evaluation provide adequate reassurance?

BACKGROUND: Involuntary weight loss frequently poses a diagnostic challenge. Patient and physician alike want to exclude malignant and other major organic illness. The present study aimed to evaluate whether a negative baseline evaluation (consisting of clinical examination, standard laboratory examination, chest X-ray, and abdominal ultrasound) lowers the probability of evolving organic illness in patients with significant unexplained weight loss. METHODS: Prospective observational study of 101 consecutive patients presenting to a general internal medicine department of a university hospital with an unexplained unintentional weight loss of at least 5% within 6-12 months. Laboratory tests of interest included C-reactive protein, albumin, haemoglobin, and liver function tests. RESULTS: Weight loss of the 101 patients [age (mean, interquartile range): 64 (51-71) years, 46% male] averaged 10 (7-15) kg. Organic causes were found in 57 patients (56%), including malignancy in 22 (22%). In 44 patients without obvious organic cause for the weight loss (44%), a psychiatric disorder was implicated in 16 (16%) and no cause was established in 28 (28%), despite vigorous effort and follow-up of at least 6 months. Baseline evaluation was entirely normal in none of the 22 patients (0%) with malignancy, in 2 of the 35 (5.7%) with non-malignant organic disease, and in 23 of the 44 (52%) without physical diagnosis. Additional testing, oftentimes extensive, after a normal baseline evaluation led to one additional physical diagnosis (lactose intolerance). CONCLUSION: In patients presenting with substantial unintentional weight loss, major organic and especially malignant diseases seem highly unlikely when a baseline evaluation is completely normal. In this setting, a watchful waiting approach may be preferable to undirected and invasive testing.

Sequential therapy with cefuroxime and cefuroxime-axetil for community-acquired lower respiratory tract infection in the oldest old.

BACKGROUND AND AIMS: Community acquired lower respiratory tract infection (CALRTI) is the most common infection requiring hospitalization in the elderly. Sequential antibiotic therapy offers the potential for earlier functional rehabilitation, shorter length of hospital stay and lower costs. We studied the efficacy and safety of an empiric sequential antibiotic therapy with cefuroxime-cefuroxime axetil in elderly patients hospitalized with a CALRTI. METHODS: A prospective, randomized, open-label, in-hospital study of cefuroxime IV 750 mg tid for 10 days (IV group) vs cefuroxime 750 mg IV tid for 3 days, followed by cefuroxime-axetil PO 500 mg bid for 7 days (sequence group), when clinical (symptoms improved and fever disappeared) and/or laboratory response [decrease in C-reactive protein (CRP)] occurred. RESULTS: A total of 142 patients, 71 (mean age: 83.3 (+/-6 SD), M/F ratio: 1.1) in the IV group, and 71 (mean age: 81.5 (+/-7 SD), M/F ratio: 1.5) in the sequence group, were included in the study. Eighty-three (58.4%) presented with radiologically confirmed pneumonia (CAP) and 59 (41.6%) with non-pneumonic LRTI (NPLRTI) (p=ns between study groups). Treatment was considered effective in 84.5% (60/71) of patients in the IV group and 80.3% (57/71) in the sequence group (p=ns). Therapy failed in 15% (21/142) of the study population (p=ns between study groups) and, after day 3 of therapy, 8.45% (6/71) failed in both study groups. By the end of treatment, two patients had died in each study group, and total in-hospital mortality was 8.5% (12/142, p=ns between study groups). The length of hospital stay (LOS) did not differ between the two study groups. CONCLUSIONS: When a favorable clinical or biochemical response occurs on day 3 of IV cefuroxime therapy, further therapy with oral cefuroxime-axetil is as effective and safe as a full course of cefuroxime IV in elderly patients hospitalized with CALRTI. However, LOS was not reduced after sequential antibiotic therapy in this population.

Recurrent fevers of unknown origin.

Recurrent fever of unknown origin is mostly caused by rather rare diseases and many cases remain unexplained. The very limited literature data do not allow one to construct a diagnostic algorithm. A number of general principles should be kept in mind before starting the investigation for this rare subtype of fever of unknown origin.

Retropharyngeal calcific tendonitis.

Calcific tendonitis of the longus colli muscle is an uncommon cause of sudden onset of neck pain. Differential diagnosis should include retropharyngeal abscess, traumatic injury or even meningitis. Diagnosis can be made radiographically with plain radiograph which reveals an amorphous calcification anteriorly to C1-C2 and severe swelling of the prevertebral soft tissue. Treatment of choice is conservative and consists of administration of nonsteroidal anti-inflammatory drugs. Clinically the complaints disappear after 1-2 weeks. Follow-up radiographs are, in fact, unnecessary but demonstrate complete resolution of the calcific density and normalization of the prevertebral swelling.

Urea-splitting urinary tract infection contributing to hyperammonemic encephalopathy.

BACKGROUND: We present a case of severe neurological symptoms caused by hyperammonemia, secondary to a urinary tract infection with urea-splitting bacteria. INVESTIGATIONS: Blood analysis, urinalysis, urine culture, abdominal ultrasonography, cystography, CT. DIAGNOSIS: Hyperammonemia as a result of urinary tract infection with urea-spliting bacteria. MANAGEMENT: Desobstruction of the urinary tract and bladder or pouch rinsing, antibiotics, reduction of the dietary and endogenous nitrogen load, and endogenous nitrogen breakdown. Identification, prevention and treatment of underlying causes.

Cardiac involvement in systemic inflammatory diseases.

Systemic inflammatory diseases represent a large group of rare diseases that may involve all organs and also the heart. The three layers of the heart can be affected and some manifestations such as pericarditis in systemic lupus erythematosus are rather well known, yet others are not known even for cardiologists. Modern sophisticated imaging techniques reveal cardiac abnormalities in most of these diseases and the reported frequency of cardiac involvement ranges widely depending upon the applied diagnostic methods and selection of patients. The clinical significance of these findings is not always established. However, better knowledge and awareness of cardiac involvement is necessary because it conveys a major risk for mortality in several of these rare diseases.

Extremely elevated C-reactive protein.

BACKGROUND: C-reactive protein (CRP) is a widely used inflammatory marker. Yet, the clinical significance and outcome of extremely elevated CRP levels are poorly characterized. METHODS: We collected all patients seen at a university hospital in 2004 with at least one CRP level above 500 mg/l and retrospectively analyzed their electronic files, focusing on patient characteristics, clinical diagnosis, microbiology and vital outcome. RESULTS: CRP was above 500 mg/l in 130 patients with a median age of 62 years. Patient characteristics, settings, etiologies of inflammation, comorbidities and microbiology varied widely. Infections, mainly bacterial, accounted for 88% of episodes. Outcome was fatal in 36% of all patients and in 61% of patients with active malignancies. CONCLUSION: A wide variety of infections, especially bacterial, that are generally readily identified account for the majority of instances of extreme CRP elevation. Mortality is high, certainly in oncological patients.

Idiopathic renal infarction.

BACKGROUND: Renal infarction may be an underrecognized disorder. Classical teaching holds that cardioemboli, notably in the setting of arterial fibrillation, are responsible. The expanding use of contrast enhanced computed tomography (CT) in patients with acute abdomen may change the spectrum of renal infarction. METHODS: Twenty-seven consecutive patients presenting to a single university hospital with nontraumatic CT-documented acute renal infarction were studied and stratified according to the presence or absence of cardiac disease, either obvious at presentation or detected during work-up. RESULTS: Eleven patients (41%) had obvious cardiac disease, including atrial fibrillation in all but one. Sixteen patients (59%) had no discernible structural or arrhythmic cardiac disease and were classified as idiopathic group. Patients in the idiopathic group were significantly younger (median age in years [interquartile range]: 48 [41-53] versus 75 [53-82] years, P = .003) and, besides smoking, had fewer traditional cardiovascular risk factors. CONCLUSION: Acute renal infarction may occur in individuals of middle age without risk factors for cardioembolism. In patients with renal colic without lithiasis the diagnosis of renal infarction should be considered especially if serum lactate dehydrogenase is elevated, even in the absence of atrial fibrillation.

Repetitive 18F-fluorodeoxyglucose positron emission tomography in giant cell arteritis: a prospective study of 35 patients.

OBJECTIVE: To study fluorodeoxyglucose (FDG) uptake in the different vascular beds and in the large joints of patients with giant cell arteritis (GCA) at diagnosis, during steroid treatment, and at relapse. METHODS: All consecutive patients admitted to our department with a diagnosis of GCA underwent FDG-positron emission tomography (PET) scan before treatment with methylprednisolone was started. PET scans were repeated at 3 and 6 months, if the initial PET scans showed vascular FDG uptake. PET scans were scored at 7 different vascular areas and a total vascular score (TVS) was calculated, ranging from 0 to 21. RESULTS: A total of 35 patients entered the study. At diagnosis, vascular FDG uptake was noted in 29 patients (83%), especially in the subclavian arteries (74%), but also in the aorta (>50%) and up to the femoral arteries (37%). TVS decreased from a mean +/- SD score of 7.9 +/- 5.5 at baseline to 2.4 +/- 3.5 on repeat PET scan at 3 months (P < 0.0005), but did not further decrease at 6 months. The patients who relapsed had similar earlier decreases of TVS compared with those who did not relapse. FDG uptake in the shoulders at diagnosis correlated significantly with the presence of polymyalgia rheumatica (P = 0.005). CONCLUSION: FDG uptake in the large vessels is a sensitive marker for GCA, which can involve the larger thoracic, abdominal, and peripheral arteries. Polymyalgia rheumatica symptoms in patients with GCA correlate with (peri)synovitis of the shoulders. Relapses of GCA cannot be predicted by results of former PET scintigraphies.