Mediterranean spotted fever associated with leucocytoclastic vasculitis and acute pancraeatitis.

A young healthy gardener became febrile with abdominal pain, nausea, vomiting and diarrhoea followed by palpable purpura, mostly on the legs and buttocks with associated arthralgia. Dehydration, azotemia and hyponatraemia resolved with fluid replacement. Tests demonstrated acute pancreatitis, hepatitis, thrombocytopenia, microscopic haematuria and proteinuria. He improved with doxycycline, but bipedal pitting oedema and punctate rash involving the soles/hands appeared. Microbiological tests revealed positive IgM and IgG serology for rickettsiae spotted fever. Skin biopsy of the purpura confirmed leucocytoclastic vasculitis, positive for Rickettsiae conorii by PCR amplification. Palpable purpura is a rare important manifestation of Mediterranean spotted fever (MSF), due to either secondary leucocytoclastic vasculitis or associated Henoch-Schonlein purpura (HSP), which best explains the distribution of the rash, arthralgia, gastrointestinal symptoms, and microhaematuria not usually seen in R. conorii infections. Likewise, the patient's acute pancreatitis may be interpreted as a rare presentation of HSP or a seldom-encountered feature of MSF.

Mind the caretaker: ED referrals of community-dwelling older adult patients by their primary caregivers are accurate.

BACKGROUND: ED referral of older adults on the initiative of their family or paid live-in caregiver is common but not previously studied. METHODS: ED-presenting community-dwelling patients ≥65 years were studied, emphasizing the referring agent, and correct (admitted or discharged +changed diagnosis/treatment) vs. incorrect referral (discharged, no change made). RESULTS: Of 448 consecutive patients (median age 83 years), 231 were referred by their primary physician (PCP) (73% admitted, 17% discharged +change). 117 ED referrals were initiated by their family (78% admitted, 6% discharged +change), and 100 by their paid caregiver (66% admitted, 21% discharged +change). Differences were non-significant, as was the distribution of main diagnoses. CONCLUSIONS: ED referral of older adults from the community by laymen who know the patient well (family or caregiver) is non-inferior to a referral by their PCP. ED physicians should regard non-physician ED presentations as seriously as a referral by a physician, pending confirmation in future studies.

Acute painless pancreatitis as an unusual presentation of leptospirosis in a low-incidence country.

A healthy, urban-dwelling man presented with lassitude, jaundice without increased liver enzymes or obstructive features on imaging, brief acute kidney injury, leucocytosis with near-normal C reactive protein and markedly increased serum amylase and lipase. Leptospirosis was not considered for 10 days because of the low incidence of the disease in the country, absent animal contact and physicians' low index of suspicion. Presentation without fever and without the commonly associated abdominal pain, myalgia, headache, thrombocytopaenia or elevated serum creatine kinase added to the diagnostic challenge. Once an infectious cause of acute pancreatitis was contemplated, leptospirosis was immediately sought and diagnosed by PCR of urine and microscopic agglutination test, and he fully recovered on ceftriaxone. Physicians in countries with a low incidence of leptospirosis should be more aware of the possibility of the disease even when several key features such as fever or pain are missing and the patient has a rare infectious acute pancreatitis.

[ANTIBIOTIC-ASSOCIATED ENCEPHALOPATHY].

INTRODUCTION: Antibiotic-associated encephalopathy (AAE) is a relatively uncommon adverse drug event, mostly encountered in hospitalized patients undergoing intravenous antibiotic treatment. A typical case is reported and the literature is reviewed. Most antibiotic drugs have been implicated in the pathogenesis. Varied intriguing mechanisms may be involved, in particular, binding of ß-lactams to GABA(A) receptors interfering with inhibitory neurotransmission and therefore enhancing bursts of excitatory neurons. Usually occurring within the first week of treatment commencement, AAE may present with myriad symptoms in different combinations that include impaired consciousness, agitation, hallucinations, delusions, seizures (often nonconvulsive), myoclonus, and cerebellar signs. Laboratory workup and neuroimaging are non-contributory, but EEG usually reveals triphasic waves, characteristic of encephalopathies, but nonspecific. Renal impairment is often an important risk factor, and high drug doses and prior brain disease are additional risk factors. Discontinuation of the offending drug is followed by resolution of the encephalopathy within a median of 5 days. Better awareness of the syndrome by clinicians will improve timely recognition and treatment of antibiotic-associated encephalopathy, which may be more frequently encountered with the increasing use of antibiotics.