Acute painless pancreatitis as an unusual presentation of leptospirosis in a low-incidence country.

A healthy, urban-dwelling man presented with lassitude, jaundice without increased liver enzymes or obstructive features on imaging, brief acute kidney injury, leucocytosis with near-normal C reactive protein and markedly increased serum amylase and lipase. Leptospirosis was not considered for 10 days because of the low incidence of the disease in the country, absent animal contact and physicians' low index of suspicion. Presentation without fever and without the commonly associated abdominal pain, myalgia, headache, thrombocytopaenia or elevated serum creatine kinase added to the diagnostic challenge. Once an infectious cause of acute pancreatitis was contemplated, leptospirosis was immediately sought and diagnosed by PCR of urine and microscopic agglutination test, and he fully recovered on ceftriaxone. Physicians in countries with a low incidence of leptospirosis should be more aware of the possibility of the disease even when several key features such as fever or pain are missing and the patient has a rare infectious acute pancreatitis.

[ANTIBIOTIC-ASSOCIATED ENCEPHALOPATHY].

INTRODUCTION: Antibiotic-associated encephalopathy (AAE) is a relatively uncommon adverse drug event, mostly encountered in hospitalized patients undergoing intravenous antibiotic treatment. A typical case is reported and the literature is reviewed. Most antibiotic drugs have been implicated in the pathogenesis. Varied intriguing mechanisms may be involved, in particular, binding of ß-lactams to GABA(A) receptors interfering with inhibitory neurotransmission and therefore enhancing bursts of excitatory neurons. Usually occurring within the first week of treatment commencement, AAE may present with myriad symptoms in different combinations that include impaired consciousness, agitation, hallucinations, delusions, seizures (often nonconvulsive), myoclonus, and cerebellar signs. Laboratory workup and neuroimaging are non-contributory, but EEG usually reveals triphasic waves, characteristic of encephalopathies, but nonspecific. Renal impairment is often an important risk factor, and high drug doses and prior brain disease are additional risk factors. Discontinuation of the offending drug is followed by resolution of the encephalopathy within a median of 5 days. Better awareness of the syndrome by clinicians will improve timely recognition and treatment of antibiotic-associated encephalopathy, which may be more frequently encountered with the increasing use of antibiotics.

Objective and subjective handicap following spinal cord injury: interrelationships and predictors.

OBJECTIVE: To investigate the relationship between objective and subjective indicators of handicap or community participation among people with spinal cord injury (SCI) 1 year postinjury. DESIGN: Longitudinal correlational study of quality of life indicators linked to Northern New Jersey SCI System database. SETTING AND PARTICIPANTS: A total of 126 (80% male) participants was assessed at 1 year post-SCI. Age ranged from 14-83 years (median age = 34 years); 47% had tetraplegia, and 53% had paraplegia. PRIMARY MEASURES: Objective (or normative) handicap was measured using the Craig Handicap Assessment and Reporting Technique and the Community Integration Questionnaire. Subjective feelings about each area of handicap or community participation were assessed using the Andrews Delighted-Terrible scale. RESULTS: Significant correlations were found between objective and subjective indicators of handicap in work life, social life, mobility, and economic status. Subjective handicap also correlated modestly with severity of impairment and length of hospitalization. These correlations were, however, weak or inconsistent across individuals. Subjective quality of life was not related to preinjury economic or social handicap. Some participants spontaneously reported dissatisfaction with items outside of the standard outcomes scales used (eg, sexuality and personal relationships). CONCLUSIONS: The weakness and inconsistency of relationships between objective and subjective appraisals of areas of community participation is a challenge to outcomes measurement and has implications for the targeting of interventions. More research is needed to understand relationships between objective indicators of community participation and subjective appraisals of these areas.