Reactivation of latent Histoplasma and disseminated cytomegalovirus in a returning traveller with ulcerative colitis.

INTRODUCTION: We describe a case of progressive disseminated histoplasmosis (PDH) and disseminated cytomegalovirus (CMV) with development of haemophagocytic lymphohistiocytosis in a 62-year-old man of Bangladeshi origin living in the UK. CASE PRESENTATION: The patient had a background of ulcerative colitis for which he took prednisolone and azathioprine. He presented with fever, lethargy, cough, weight loss and skin redness, and was initially treated for bacterial cellulitis and investigated for underlying malignancy. He developed multiple progressive erythematous skin lesions, sepsis and colitis requiring management on intensive care. A skin biopsy showed yeasts in the dermis and sub-cutaneous fat, which were confirmed as Histoplasma capsulatum by PCR. Disseminated CMV with evidence of end organ gastrointestinal disease was also diagnosed. Despite anti-viral and anti-fungal treatment, the patient deteriorated with evidence of bone marrow suppression and a diagnosis of haemophagocytic lymphohistiocytosis was made. CONCLUSION: PDH is classically seen in patients with significant immunosuppression, e.g. those with human immunodeficiency virus (HIV) or on anti-TNF therapy; however, we present a case of reactivation of Histoplasma in a non-HIV patient. We consider the importance of contemplating reactivation of endemic mycoses and CMV in critically unwell and deteriorating patients.

Myocardial infarction in intensive care units: A systematic review of diagnosis and treatment.

INTRODUCTION: Patients in the intensive care unit are vulnerable to myocardial injury from a variety of causes, both ischaemic and non-ischaemic. It is challenging for ICU clinicians to apply the conventional guidance concerning diagnosis and treatment. We conducted this review to examine the evidence concerning diagnosis and treatment of myocardial infarction in the ICU. METHODS: A systematic review was performed to identify relevant studies. RESULTS: 19 studies concerning use of ECG, cardiac enzymes, echocardiography and angiography were identified. 4 studies considered treatment of myocardial infarction. CONCLUSIONS: Regular 12 lead ECG or 12 lead ECG monitoring is more sensitive than 2 lead monitoring, regular measurement of cardiac enzymes is more sensitive than when provoked by symptoms. Coronary angiography rarely identifies treatable lesions, without regional wall motion abnormality on echocardiography. Evidence relating to treatment was limited. A potential strategy to diagnose myocardial infarctions in the ICU is proposed.

The FIM instrument to identify patients at risk of falling in geriatric wards: a 10-year retrospective study.

OBJECTIVES: the main objective was to evaluate if the admission functional independence measure (FIM) score could be used to predict the risk of falls in geriatric inpatients. DESIGN: a 10-year retrospective study was performed. SETTING: the study was conducted in a 298-bed geriatric teaching hospital in Geneva, Switzerland. SUBJECTS: all patients discharged from the hospital from 1 January 1997 to 31 December 2006 were selected. MAIN OUTCOME MEASURES: measures used were FIM scores at admission using the FIM instrument and number of falls extracted from the institution's fall report forms. RESULTS: during the study period, there were 23,966 hospital stays. A total of 8,254 falls occurred. Of these, 7,995 falls were linked to 4,651 stays. Falls were recorded in 19.4% of hospital stays, with a mean incidence of 7.84 falls per 1,000 patients-days. Although there was a statistically significant relationship between total FIM score, its subscales, and the risk of falling, the sensitivity, specificity, positive predictive value and negative predictive value obtained with receiver operating characteristic curves were insufficient to permit fall prediction. This might be due in part to a non-linear relationship between FIM score and fall risk. CONCLUSION: in this study, the FIM instrument was found to be unable to predict risk of falls in general geriatric wards.