A febrile old man with xanthochromic hypoglycorrhachia.

INTRODUCTION: Meningitis is a commonly seen disease in the daily practice of emergency departments. Cerebrospinal fluid (CSF) examination including Gram stain and culture are crucial for identifying between bacterial and viral meningitis and should be completed prior to antibiotic administration. Hypoglycorrhachia is one of the certain independent predictors of bacterial meningitis. CASE REPORT: A 69-year-old male having a past medical history of alcoholism and liver cirrhosis presented to the emergency department with intermittent fever and chills for one day. Sudden onset of a tonic-clonic seizure for a few minutes with agitation, and neck stiffness on physical examination were noted. Lumbar puncture was performed and xanthochromic turbid cerebrospinal fluid (CSF) was retrieved. CSF analysis showed pleocytosis with a white blood cell count of 4608/cm2; the neutrophil-to-lymphocyte ratio was 96:4. The CSF also showed extreme hypoglycorrhachia (4 mg/dL) and high protein levels (865 mg/dL) were noted. Bacterial meningitis was diagnosed. The CSF yielded Klebsiella pneumoniae on the third day of admission. After 4 weeks of meropenem complete treatment, the patient recovered uneventfully without any neurological deficit and was discharged one1 month later. DISCUSSION: Hypoglycorrhachia is one of the certain independent predictors of bacterial meningitis. Elevated CSF protein over 150 mg/dL may turn normal crystal-clear CSF into yellowish or turbid CSF. Aerobic Gram-negative bacteria like Klebsiella species are uncommon community-acquired pathogens and are more likely to occur after neurosurgical procedures complicated with pyogenic liver abscess and septic endophthalmitis. The appropriate antibiotic should be monitored and adjusted clinically. CONCLUSIONS: In febrile patients, epileptic episodes may hint towards an inflammatory process in the central nervous system. Grossly turbid and xanthochromic CSF with hypoglycorrhachia raise the concern for bacterial meningitis. Adequate antibiotic adjustment according to CSF culture results can also lead to the successful outcome without neurologic deficits.

Herb induced liver injury after using herbal medicine: A systemic review and case-control study.

In Taiwan, traditional herbal medication was included in Taiwan's National Health Insurance (NHI) system since 1996 and in 9 out of 10 hospitals have developed their own departments of traditional medicine. This study aims to address the herb-induced liver injury (HILI) after using herbal medicine on the relationship between age, gender, epidemiology, laboratory data, pathogenesis, mobility, and mortality.We searched the PubMed database with "hepatitis after herbal medicine" and "in human" till 2018 April and returned 163 articles in a systemic review manner. Two cases reports describing in-vitro liver injury were excluded. Reviews and articles without the detailed report, laboratory data and history were excluded from this study. In the end, there were 53 articles enrolled in this study. These enrolled literatures are from France (n = 13), Germany (n = 12), Switzerland (n = 5) United States of America (n = 4), Korea (n = 4), Hong Kong (n = 4), Greece (n = 3), China (n = 2), Canada (n = 1), Italy (n = 1), Thailand (n = 1), Finland (n = 1), Taiwan (n = 1), and Japan (n = 1). The data were analyzed with a commercial statistical software Stata/SE 12.0 program Stata Corporation, College Station, TX, USA. Statistical χ tests were performed and the significance was set at a P value of less than .05 (2-tailed).The ages are ranged from 15 to 78 years with the mean ±â€ŠSD (standard deviation) of 48.3 ±â€Š16.2 years old. The majority of cases are female (n = 37). In elderly, man is more commonly seen than female in HILI (37.5% vs 10.5%, P = .02). Female is vulnerable to cholestatic type of HILI than male (21.1% vs 0.0%, P = .04). Of all the cases in HILI, using pure substance are more commonly seen than mixed substance (P = .02). In gender, male patients have higher alanine aminotransferase (GPT) (IU/L) level in HILI than female ones (1560 ±â€Š819 vs 1047 ±â€Š706, P = .03).In HILI, the female is more commonly seen than male, but less than male in the elderly. The pure substance more often happens to HILI than mixture substance. Female is predominant in the cholestatic type of HILI. The major prevalence of HILI is in Europe rather than Asia. HILI cases in Europe is 2.75-fold than in Asia. This could be due to fewer reports of the herb induced liver injury in Asia compared to Europe. Prevention of HILI is the best policy, because it needs to take 78 ±â€Š59 days to recover.

Successful Resuscitation of a Young Girl Who Drank Rivastigmine With Respiratory Failure.

Rivastigmine is a non-competitive reversible inhibitor of acetylcholinesterase which is approved as one of the fi rst-line treatment options for Alzheimer's disease. We present the case of a 33-year-old woman with acute cholinergic syndrome secondary to deliberate rivastigmine poisoning. The patient presented at the emergency department (ED) with drowsy consciousness, dizziness, vomiting, diarrhea, sweating, and hypertension (171/103 mmHg). At the scene, an empty bottle of Rivast 120 mL/Bot, containing rivastigmine 2 mg/mL, was found beside the patient. Two hours later, we noted bronchorrhea and persistent salivation along with drowsiness, agitation, fatigue, incontinence, and limbs paralysis. A notably low serum cholinesterase level (651 U/l) was identified. Acute cholinergic syndrome secondary to rivastigmine intoxication was diagnosed. Endotracheal intubation with ventilator support was required due to respiratory failure. Atropine (0.5 mg intravenous injection) was administered. She was subsequently admitted to the intensive care unit for further care. Extubation was performed on the third day. The patient insisted on being discharged on the second day after extubation, and after administration of a total of 11 mg of atropine, no signs of either intermediate syndrome or delayed polyneuropathywere noted. rivastigmine, an acetylcholinesterase inhibitor, can precipitate an acute cholinergic crisis in cases of intoxication. Typical clinical features of cholinergic excess include increased secretions in the airway and oral cavity, miosis, diarrhea, anxiety, twitching, bronchoconstriction, convulsions, confusion, and gastrointestinal and muscular cramps. The treatment for acute cholinergic crisis is administration of atropine alone or in combination with an antidote to the cholinesterase inhibitor (such as pralidoxime). Patients often recover well with atropine supplements and optimal supportive care.

Promoter knock-in mutations reveal a role of Mcl-1 in thymocyte-positive selection and tissue or cell lineage-specific regulation of Mcl-1 expression.

We previously demonstrated that IL-3 stimulates transcription of the antiapoptotic gene mcl-1 via two promoter elements designated as the SIE and CRE-2 sites. To further study the functional role of these two DNA elements, mutant mice with targeted mutations of both SIE and CRE-2 sites (SC mutants) were generated. Homozygous SC mutants manifested a markedly reduced level of Mcl-1 in thymus but not in other major organs such as spleen, liver, lung, or heart. Reduced expression of Mcl-1 in SC mutant thymus resulted in attenuated positive selection of double-positive thymocytes into both CD4 and CD8 lineages, a result likely due to reduced survival of SC mutant double-positive thymocytes that were supposed to be positively selected. In contrast, in the peripheral lymphoid organs, only CD8(+) but not CD4(+) T cells were significantly reduced in homozygous SC mutant mice, a result consistent with a more dramatic decrease both of Mcl-1 expression and cell viability in mutant CD8(+) compared with mutant CD4(+) T cells. Impaired T cell development and peripheral CD8(+) lymphopenia in homozygous SC mutant mice were both cell autonomous and could be rescued by enforced expression of human Mcl-1. Together, the promoter-knock-in mouse model generated in this study not only revealed a role of Mcl-1 in thymocyte-positive selection, but also uncovered that Mcl-1 expression is regulated in a tissue or cell lineage-specific manner.