July 2004: 40-year-old man with headaches and dyspnea.

A 40-year-old man had a 6-week history of severe frontal headaches and dry cough. Chest x-ray showed hilar adenopathy with bilateral parenchymal infiltrates. A diagnosis of atypical pneumonia was made. Four weeks later he was admitted with persistent headache. Infectious screen was negative. Brain MR post contrast, revealed cerebellar enhancement and swelling with moderate tonsillar herniation; findings which precluded the performance of a lumbar puncture. High resolution CT thorax confirmed hilar abnormalities; shown by microscopy to represent non caseating granulomata. A presumptive diagnosis of sarcoidosis was reached. Despite an initial symptomatic improvement his headache persisted. Repeat MRI, eleven days after admission, showed reduced cerebellar enhancement and swelling with no change in the degree of tonsillar herniation. He deteriorated acutely and died two weeks after admission. Autopsy revealed cerebral oedema with tonsillar herniation secondary to cryptococcal meningitis variety neoformans. There was no evidence of neurosarcoid. Active and inactive sarcoid was identified in the lungs and hilar nodes with no evidence of systemic sarcoid. Focal evidence of cryptococcal pneumonitis was present in the lung as a necrotic focus. A strong index of clinical suspicion is necessary to diagnose the rare association of cryptococcus complicating sarcoidosis.

Baseline coagulation assay values for northern elephant seals (Mirounga angustirostris), and disseminated intravascular coagulation in this species.

Coagulation assays, including platelet counts, antithrombin III, fibrinogen, fibrinogen degradation product levels, prothrombin (PT), activated partial thromboplastin (APTT) and activated clotting times (ACT), were performed on 20 healthy juvenile northern elephant seals (Mirounga angustirostris) stranded along the central California coastline from 15 March to 15 April 1994, to establish baseline parameters for this species. Elephant seals appear to have relatively short ACT, PT, and APTT times, while fibrinogen, platelet and antithrombin III levels are similar to domestic species. Based on these mean values in healthy animals, disseminated intravascular coagulation (DIC) was diagnosed in an elephant seal with low plasma fibrinogen and extended ACT, PT and APTT times; this animal had hemorrhages, mixed bacterial suppurative interstitial pneumonia with verminous arteritis, epicarditis, hepatitis and enterocolitis.