Lesson of the month 1: Lemierre's syndrome: a reminder of the 'forgotten disease'.

Lemierre's syndrome is a condition characterised by suppurative thrombophlebitis of the internal jugular (IJ) vein following a recent oropharyngeal infection, with resulting septicaemia and metastatic lesions. It is strongly associated with Fusobacterium necrophorum, a Gram-negative bacilli. Key to early diagnosis is awareness of the classical history and course of this illness, and therefore to ask about a history of recent oropharyngeal infections when a young patient presents with fever and rigors. Diagnosis can be confirmed by showing thrombophlebitis of the IJ vein, culturing F necrophorum from normally sterile sites or demonstrating metastatic lesions in this clinical setting. The cornerstone of management is draining of purulent collection where possible and prolonged courses of appropriate antibiotics. In this article, we review a case study of a young man with Lemierre's syndrome and discuss the condition in more detail.

Pneumatosis Intestinalis and Intestinal Perforation in a Patient Receiving Tocilizumab.

In this article, we report a case of pneumatosis intestinalis associated with tocilizumab use. This is a unique case and may explain the increased rate of idiopathic bowel perforation among patients taking tocilizumab.

Teriparatide and vertebral fracture healing in Ankylosing Spondylitis.

Patients with Ankylosing Spondylitis (AS) are four times more likely to sustain spinal fractures. Due to the associated risk of neurological complications treatment is complex. We present the case of a 56-year-old Caucasian gentleman with AS who sustained a fracture of T2 vertebra following a traumatic hyperextension injury. He declined surgery in fear of complications and started treatment with subcutaneous Teriparatide at a dose of 20 mg daily for six months. There was complete healing of the vertebral fracture at 6 months without any complications. This case is unique as complete healing was achieved without preceding surgical intervention. Further exploration of the use of Teriparatide in spinal fractures in patients with AS is recommended to support the theories generated by this and other existing cases in the literature.

Recent developments in the treatment of patients with systemic lupus erythematosus: focusing on biologic therapies.

INTRODUCTION: Major trials hoping to obtain optimal disease control in systemic lupus erythematosus (SLE) are ongoing. Given its complex aetiology and pathogenesis, it is not surprising that multiple therapeutic targets have emerged and that none are uniformly successful. AREAS COVERED: In this review, we highlight the recent, more significant studies focusing on the use of biologic therapies. There has been great emphasis on the role of B cells in SLE and many uncontrolled studies have encouraged the use of rituximab (an anti-CD20 monoclonal). Disappointingly, two major trials, EXPLORER and LUNAR did not confirm its utility, although doubts have been expressed on their trial design, and other trials using this drug are commencing. In contrast, belimumab, which blocks a B-cell activating factor, did meet its end points in two major randomised controlled clinical trials and has been approved for use in SLE by both the FDA and the European Medicines Agency. Encouraging, albeit preliminary, results with epratuzumab (which blocks CD22) have also been reported. EXPERT OPINION: In addition to targeting B cells, other approaches including biologics, which modulate T-cell function and block interleukin-6 and interferon-α, have been explored. Finally, we review the recent developments in the use of conventional drugs, such as cyclophosphamide and mycophenolate.

Clozapine induced tubulointerstitial nephritis in a patient with paranoid schizophrenia.

We describe the development of tubulointerstitial nephritis after starting clozapine therapy in a patient with treatment-resistant schizophrenia. A 54-year-old mixed-race patient with a longstanding history of paranoid schizophrenia was started on the antipsychotic clozapine. Two months after starting clozapine he developed fevers, cough and acute renal failure which initially responded to 7 days of prednisolone but recurred after completing the steroid course. Renal biopsy confirmed acute tubulointerstitial nephritis and he was started on a course of steroids with renal recovery in 72 h. Clozapine was later stopped. This case highlights a serious and potential life-threatening complication of an important antipsychotic used in treatment-resistant schizophrenia.