Azithromycin versus erythromycin infusions prior to endoscopy in upper gastrointestinal bleeding.

Background: Intravenous erythromycin prior to endoscopy for upper gastrointestinal bleeding (GIB) improves outcomes but requires immediate preparation delaying administration in emergency cases. Azithromycin is readily available and does not require prolonged preparation. The aim of the study was to assess the effect of azithromycin in improving the quality of endoscopic visualization in upper GIB compared to erythromycin. Methods: Patients admitted with upper GIB who received erythromycin or azithromycin before urgent endoscopy were included. Primary outcome of the quality of visualization was assessed by two gastroenterologists, blinded to the choice of infusion, using a scoring system ranging from 0 to 8, with a maximum of 2 points assigned to the fundus, body, antrum and bulb. Results: Sixty-six patients were included; 25 received azithromycin and 41 received erythromycin. Mean total visualization score was significantly higher with azithromycin compared to that with erythromycin (6.8±1.4 vs. 5.5±2.2, respectively; P=0.01) and remained significant after adjusting for confounders (Diff: 0.01, 1.88; P=0.05). Secondary outcomes analyses showed a shorter LOS when given azithromycin compared to erythromycin [6 (3 to 9) vs. 8 (7 to 16) days, respectively, 95% CI: 1.03, 3.89; P=0.04]. Time between initiating the infusion and endoscopy was longer with azithromycin (Diff: 40.64 min; 95% CI: 7.23, 74.05; P=0.02). Need for second look endoscopy, procedure time, blood transfusion requirements and procedure-related complications did not differ between the groups. Conclusions: Azithromycin infusion before endoscopy for upper GIB was associated with better visualization than that of erythromycin. Randomized trials are needed to validate these findings.

Toxoplasma myocarditis: An atypical case in an immunocompetent patient.

Myocarditis occurs with a variety of infectious agents including viruses, bacteria, protozoa and parasites. We present a rare case of myocarditis secondary to Toxoplasma gondii in a 23-year-old immunocompetent male presenting with acute chest pain. Workup revealed evidence of biventricular myocarditis on cardiac magnetic resonance imaging, elevated Toxoplasma serologies with rising titers over time. The patient was treated with sulfadiazine and pyrimethamine for eighteen days with resolution of symptoms. This case highlights alternative diagnostic and treatment modalities for Toxoplasma myocarditis in immunocompetent hosts.