False positive metastatic disease due to combined thoracic and subcutaneous splenosis.

A 56-year-old man presented with dyspnea secondary to pulmonary emboli and dilated cardiomyopathy. His past medical history included a history of emergency laparotomy, splenectomy, and splenic flexure resection following a gunshot injury 30 years ago. CT and MRI imaging demonstrated multiple homogeneously enhancing lobulated lesions at the left-sided pleura and chest wall with an irregular calcified spleen. The aforementioned lesions demonstrated a similar level of tracer uptake to the splenic activity with no evidence of other FDG avid malignancy on the follow-up 18F-FDG PET study. All the above-mentioned pleural and chest wall lesions demonstrated intense tracer accumulation on technetium-99m labeled heat-damaged red cell scintigraphy, consistent with combined thoracic and subcutaneous splenosis.

Bronchial artery to pulmonary artery fistula in a patient with cavitating tuberculosis-Demonstration with 4D CTA.

We present a case of a bronchial artery to pulmonary artery fistula. This occurred in a 77-year-old male of Bangladeshi ethnicity with a new diagnosis of cavitating pulmonary tuberculosis. A 4D CTA protocol was required to elicit the nature of the vascular abnormality. Fistula between bronchial and pulmonary arteries is an uncommon phenomenon, with few published cases. This case demonstrates the difficulty with which these fistulae are imaged. 4D CTA is a technique that is increasingly being shown to be useful in characterizing vascular anomalies such as fistulae, with embolization as the mainstay of treatment.

Use of GeneXpert MTB/RIF on a single pooled sputum specimen to exclude pulmonary tuberculosis among hospital inpatients placed in respiratory isolation.

BACKGROUND: Patients with suspected pulmonary tuberculosis (PTB) are usually placed in respiratory isolation awaiting three sputum smear microscopy results for acid-fast bacilli (3AFB). GeneXpert MTB/RIF (Xpert) on a pooled sample from two sputa may allow for more rapid de-isolation. OBJECTIVES: To compare the sensitivity and negative predictive value (NPV) of Xpert performed on a single pooled sputum sample ('pooled Xpert') to 3AFB, in order to exclude PTB in patients placed in respiratory isolation. METHODS: Hospital inpatients in respiratory isolation for possible PTB were enrolled prospectively. Three expectorated sputum samples were obtained for smear microscopy. Two of the same samples had 0.5 ml removed from each and pooled for pooled Xpert. The diagnostic accuracy of pooled Xpert and 3AFB were assessed and compared to liquid culture at 8 weeks as the reference standard. RESULTS: Of 56 participants, nine (16.1%) were diagnosed with PTB. Compared to liquid culture, pooled Xpert had a sensitivity of 88.9% (95% confidence interval (CI) 57-99%) and NPV of 97.9% (95% CI 89-99%). 3AFB had a sensitivity of 66.7% (95% CI 35-88%) and NPV of 93.5% (95% CI 83-98%). CONCLUSIONS: A single pooled Xpert was non-inferior to 3AFB, with a strong trend towards greater sensitivity and better NPV. These findings support the use of a single pooled Xpert as an effective rapid screening approach for ruling out PTB in low incidence settings. Its value in high incidence settings and optimal combination with smear microscopy and culture warrant further evaluation.

Cellulitis in older people over 75 years - are there differences?

AIM: To examine differences in risk factors, clinical features and outcomes of cellulitis between those 75 + years and those <75 years admitted to a metropolitan hospital. METHODS: A prospective study of patients with limb cellulitis requiring intravenous antibiotics conducted at Bankstown-Lidcombe Hospital, Australia from June 2014 to April 2015. RESULTS: Thirty one patients were 75 + years and 69 less than 75 years. A greater proportion of older patients resided in nursing home (25.8% vs 2.9% respectively, p = 0.001) and mobilized with walking aid(s) (58.1% vs 11.6% respectively, p < 0.001). Significantly more older patients had documented hypertension (45.2% vs 23.2% respectively p = 0.035), atrial fibrillation (33.5% vs 5.8% respectively, p < 0.001), dementia (22.6% vs 1.4% respectively, p = 0.001) and malignancy (16.1% vs 1.4% respectively, p = 0.010). The clinical presentation of cellulitis and cellulitis severity (Eron classification) did not significantly differ in both groups; however older patients were more likely to have dependent edema (OR 4.0, 95%CI 1.3-12.6, p = 0.018) and less likely to be obese (OR 0.3, 95%CI 0.1-0.8, p = 0.012) or had a past history of cellulitis (OR 0.3, 95%CI 0.1-1.0, p = 0.044) on presentation. Despite the age difference, there were no major differences in intravenous antibiotic choice, hospital length of stay, and hospital readmission rates in both groups. Older patients however, were more likely to experience complications such as falls and/or decreased mobility (38.7% vs 15.9% respectively, p = 0.020) during the cellulitis episode. CONCLUSION: There are minor differences in the risk factors and clinical features of cellulitis in older patients as compared to the young. Outcomes are similar except for a higher incidence of hospital related complications.

Out Of Hospital And In Hospital Management Of Cellulitis Requiring Intravenous Therapy.

BACKGROUND: Cellulitis requiring intravenous therapy can be managed via out of hospital programs, but a high number of patients are still admitted to hospital. OBJECTIVE: We aimed to review the clinical features, management and outcomes of patients with cellulitis requiring intravenous therapy in a Hospital in the Home (HITH) program compared to patients who are admitted to hospital. METHODS: A prospective cohort study of patients with limb cellulitis requiring intravenous antibiotics was conducted at a metropolitan principal referral hospital. RESULTS: A total of 100 patients out of 113 eligible patients were recruited. Forty-eight were treated entirely in hospital and 52 were treated entirely or partially via HITH. Patients treated in hospital were older (mean 69.2 vs 56.7 years, p<0.001), less mobile, have more comorbidities (Charlson Comorbidity Index mean 2.2 vs 1.2, P=0.005) and more associated active illness. All patients with Eron Class III were admitted to hospital. Patients treated in hospital had a higher incidence of acute renal failure (27.1% vs 3.8%, p=0.001), nosocomial infection (10.4% vs 0.0%, P=0.023), and a higher 28-day hospital readmission rate (10.4% vs 0.0%, P=0.023). CONCLUSION: Approximately half of the patients who require intravenous therapy can be treated via an out of hospital program. Patients admitted to hospital were more unwell and more likely to suffer complications. The presence of comorbid illness does not necessarily exclude participation in HITH and careful selection is essential to ensure safe outcomes.