Descending necrotizing mediastinitis: a conservative approach.

Descending necrotizing mediastinitis (DNM) is a now-rare complication of dental and pharyngeal infections. Reports in the literature have emphasized the need for early, aggressive surgical intervention. We present a case of DNM with bilateral empyemas that arose secondary to a perforated pharyngeal abscess. The patient was successfully managed conservatively with intravenous antibiotics and intercostal drainage. We conclude that conservative management with antibiotics and image-guided percutaneous pleural drainage may be initially appropriate for the stable patient.

Eosinopenia as a marker of mortality and length of stay in patients admitted with exacerbations of chronic obstructive pulmonary disease.

BACKGROUND AND OBJECTIVE: Blood eosinopenia has long been known as a marker of acute infection, and has recently been shown to be a better predictor of sepsis than CRP in critically ill patients. This study examines the usefulness of eosinopenia (< or = 0.04), for predicting the severity of exacerbations of COPD using inpatient mortality and length of stay as markers of severity. METHODS: Retrospective review of the case-notes of patients admitted with an exacerbation of COPD from March 2007 to April 2008. Patients with radiographic evidence of pneumonia and those having steroids in the previous week were excluded. Data were collected for age, length of stay, pH, WCC and mortality. RESULTS: Sixty-five patients fulfilled the inclusion criteria, 42 with a normal eosinophil count and 23 with eosinopenia. No significant differences were seen between the two groups' age, total WCC and admission pH. However, significant differences were seen in mortality (4/23 (17.4%) vs 1/42 (2.4%), P = 0.049) and length of stay (8 vs 5 days, P = 0.005) when the eosinopenia group compared with those with normal eosinophils. CONCLUSIONS: The eosinophil count might be a useful marker of severity inpatients admitted with an exacerbation of COPD independent of the WCC and pH. As it is routinely given in the full blood count in all patients admitted to hospital, there is no extra cost for this beneficial test.

Unusual recurrence of small cell lung carcinoma.

We report a case of malignant meningitis in a 63-year-old man with a background of treated small cell carcinoma. He presented with dizziness, vomiting and ataxia. His imaging investigations did not show any abnormalities, but lumbar puncture confirmed the diagnosis of malignant meningitis.

An assessment of the cost-effectiveness of fast tracking bacteriological specimens for mycobacteria.

A virtual model, using six predetermined criteria for fast tracking tuberculosis specimens was devised to improve the cost effectiveness of the MB/BacT system. All specimens received at a central laboratory were audited for the six criteria over a 6-month period. By assuming that only those specimens fulfilling these criteria were fast tracked the theoretical cost savings could be calculated. To prevent possible delay in speciating mycobacteria, the number of criteria were expanded to nine, and a further 6 month audit carried out. In the first 6-month period, 728 specimens were tested. Had the initial hypothetical criteria excluded some of the specimens, only 351 specimens would have been tested through the fast-track system at a saving of pounds sterling 942 (dollars 1696), (52%) of the total cost, but five culture results positive for environmental mycobacteria would have been delayed. In a second 6-month survey the criteria were expanded. Using these no positive culture would have been missed but the savings would only have been 26% of the total cost. Introducing exclusion criteria for rapid testing can improve the cost effectiveness of rapid culture methods with no important loss of clinically necessary information.