Levamisole-induced Vasculitis in a Hepatitis C Patient: A General Medicine Ward Perspective on Diagnosis and Management.

Purpura in hepatitis C patients has a wide range of possible etiologies, some of which include mixed cryoglobulinemia and idiopathic thrombocytopenic purpura. Levamisole is a common chemical used as a lacing agent for cocaine. It is believed to enhance the addictive properties of cocaine, but it has been associated with a vasculitis syndrome that most commonly presents with purpura and leukopenia. We report a case of a patient with hepatitis C and cocaine abuse who presented with vasculitis, thrombocytopenia, and bloody sputum. A punch biopsy was performed, which confirmed the diagnosis of levamisole-induced vasculitis. A comprehensive rheumatology workup could result in variable serology and does not provide a definitive diagnosis. We suggest performing a punch biopsy as part of the initial workup for these patients, as it can provide rapid diagnosis and is associated with a lower cost.

Comparison of three antimicrobial strategies in diabetic foot infections post-amputation.

BACKGROUND: The 2012 Infectious Disease Society of America (IDSA) guidelines recommend antimicrobial treatment of diabetic foot infections (DFIs) post-amputation, but the optimal route and duration are poorly defined. OBJECTIVE: The objective of this study was to determine whether the selection of a specific antimicrobial treatment modality affected hospital and patient outcomes. METHODS: This was a retrospective review of hospital admissions of adults admitted to ourhealthcare system with a primary diagnosis of DFIs post-amputation. The groups were separated into patients who received intravenous antimicrobials (IV), oral antimicrobials (PO), or no antimicrobials (NA). Outcomes included average length of stay among others. RESULTS: Of the 200 patients screened, 120 patients were included (IV n = 72; PO n = 20; NA n = 28). No statistically significant differences were identified in average LOS (IV = 9.97 ± 5.85, PO = 8.83 ± 7.37, NA = 9.33 ± 5.91 days; p = 0.73). However, post-operative (post-op) LOS was significantly shorter in the PO group (PO = 3.43 ± 2.56, IV = 7.34 ± 5.95, NA = 5.81 ± 4.18 days; p = 0.0001). CONCLUSION: The results of our study indicate that a PO antimicrobial treatment strategy post amputation for DFIs has the potential to decrease post-op LOS without increasing the risk of readmission. Based on the results of our study, we feel consideration should be given to transition to oral antimicrobials soon after amputation to facilitate discharge and decrease the utilization of intravenous antimicrobials.

Lorazepam versus chlordiazepoxide for the treatment of alcohol withdrawal syndrome and prevention of delirium tremens in general medicine ward patients.

Alcohol withdrawal syndrome (AWS) is a serious complication of abrupt alcohol cessation. Severe AWS can develop into delirium tremens (DT), which is potentially life-threatening. Lorazepam (LOR) and chlordiazepoxide (CDE) are mainstays of therapy for AWS. Current literature lacks studies comparing outcomes between the two drugs for patients who are not in a de-addiction ward specifically for withdrawal treatment. The primary objective of the study was to determine the incidence rate of DT between the groups. Of 2112 patients screened, 142 met inclusion criteria (LOR = 74, CDE = 68). Baseline characteristics were similar between groups. No significant difference in the primary outcome of DT development was observed (7% LOR, 9% CDE; p = 0.76). No significant differences in cumulative doses of scheduled LOR or CDE were observed (LOR 14.6 ± 8 mg, CDE 15.4 ± 12; p = 0.64). However, significant differences were found in the amount of "as needed" (PRN) LOR required for the two groups (LOR 3.2 ± 4 mg, CDE 6.6 ± 13 mg; p = 0.03) and the amount of scheduled plus PRN LOR required (LOR 17.7 ± 10 mg, CDE 21.9 ± 14 mg; p = 0.04). Doses are reported in LOR equivalents. There were no observed differences in duration of treatment (LOR 3.6 ± 1.3 days, CDE 3.9 ± 2.1 days; p = 0.3) or length of stay (LOR 5.28 ± 3.8 days, CDE 4.73 ± 4.2 days p = 0.4). No adverse events related to BZD were noted in either group. Hospital outcomes did not differ between the groups, but patients treated with CDE may require more adjuvant therapy to control symptoms of AWS. Both agents appear equally effective at preventing the development of DT in those patients admitted to general medicine wards.