Lyme radiculopathy in a septuagenarian.

A man in his 70s presented to hospital in early summer with a 5-week history of progressive lower back and right thigh pain, sensory deficit and right leg weakness. There had been limited response to analgesics in the community. Primary investigations on admission revealed no cause for his symptoms. Five days into admission, history emerged of a possible tick bite with subsequent rash sustained 3 months earlier, raising the possibility of neuroborreliosis leading to radiculopathy. Cerebrospinal fluid demonstrated a lymphocytic pleocytosis. An elevated Borrelia burgdorferi antibody index confirmed a diagnosis of Lyme neuroborreliosis. The patient was treated successfully with 28 days of intravenous ceftriaxone, analgesia and physiotherapy. Within the literature, Lyme radiculopathy is a common presentation of neuroborreliosis and should be considered and investigated in patients without radiological evidence of a mechanical cause of worsening lower back pain in settings with endemic Lyme disease.

Sinogenic polymicrobial anaerobic orbital cellulitis: the importance of source control and broad empirical antibiotics.

A man in his twenties with a history of recurrent sinusitis was urgently referred to the emergency department (ED) by an out-of-hours general practitioner following a 2-day history of increasing right eye pain, redness and swelling after a week of coryzal symptoms. He denied visual impairment and any history of recent dental pain or procedures. Initial assessment in ED noted fever, tachycardia and hypotension. Video consultation with ophthalmologist in the ED identified proptosis, periorbital erythema and chemosis with full eye movement solely affecting the right eye. Visual acuity of 6/6 was confirmed in both eyes. After review by the ear, nose and throat (ENT) team, a diagnosis of sinogenic right orbital cellulitis was made, empirical antibiotics started and care transferred to the ENT team for immediate surgical intervention. 48 hours postoperatively, the patient acutely deteriorated, developing ophthalmoplegia and visual acuity of 6/95 in the right eye. Repeat imaging demonstrated a deteriorating picture and urgent surgery was organised at a neighbouring hospital's specialist ENT unit combined with a change to his antibiotics. On day 4, 1 day following transfer, an anaerobic bacterium, Eggerthia catenaformis, was isolated from blood cultures collected on admission. The patient improved clinically following the second surgery and targeted antimicrobial therapy, eventually being discharged 10 days after initial presentation. In addition to E. catenaformis, the Anaerobic Reference Unit (Cardiff) identified two further anaerobic bacteria, Parvimonas micra and Dialister pneumosintes This paper presents the first documented case of polymicrobial anaerobic orbital cellulitis secondary to acute bacterial sinusitis. Moreover, this case underpins the importance of broad empirical antibiotics coupled with surgical source control to effectively manage a rare but sight-threatening and life-threatening disease.

Neisseria meningitidis serogroup C causing primary polyarthritis in an octogenarian.

A man in his 80s presented to the hospital with a 36-hour history of fever, myalgia, bilateral shoulder and right knee pain. Joint fluid aspirates from his shoulders and right knee isolated Gram-negative diplococci. After failing to grow on standard and selective media, Neisseria meningitidis was identified by 16s PCR and subsequently typed as serogroup C. He had no clinical features of meningitis or meningococcaemia. Blood cultures were negative and an EDTA blood sample was negative for meningococcal ctrA gene. Urine PCR was negative for Neisseria gonorrhoeae He was treated successfully with two arthroscopic joint washouts of his right knee, aspirates of both shoulders, 40 days of intravenous ceftriaxone and intensive physiotherapy as both an inpatient and outpatient. In the literature, we have not found any previously documented cases of serogroup C meningococcus causing polyarticular primary septic arthritis in this age group or guidance on duration of antibiotic treatment. Literature on the impact of rehabilitation to baseline function was also found to be lacking. Although rare, primary meningococcal arthritis (PMA) should be considered as a differential diagnosis in cases of acute polyarticular septic arthritis. Polyarticular PMA in older adults may require prolonged rehabilitation before one might expect to return to premorbid function.