Daniel Marks

Staphylococcus lugdunensis septic arthritis and epidural abscess in a patient with rheumatoid arthritis receiving anti-tumour necrosis factor therapy

A 74-year-old man with RA, well controlled on etanercept (50 mg/week) and prednisolone (7 mg/day), presented with septic arthritis affecting the right knee. He was afebrile, but hyper-reflexic in both legs with L3 L5 dermatomal sensory loss. Synovial fluid and peripheral blood cultures grew coagulase-negative staphylococci, speciated as Staphylococcus lugdunensis. MRI demonstrated an extensive epidural abscess (Fig. 1). Intravenous antibiotic therapy with flucloxacillin and sodium fusidate was initiated and etanercept was discontinued. The knee was washed out and the neurosurgical team opted to manage the abscess conservatively. Antibiotics were continued for 16 weeks, with which the neurological and radiological signs resolved and CRP normalized. Two years later the patient remains well with quiescent RA without reinstitution of biologic therapy. There are single previous reports of S. lugdunensis infecting a native joint (in a patient with longstanding RA [1]) and of epidural abscess following haematogenous seeding from cellulitis [2]. Disseminated musculoskeletal infection (including epidural abscess) as observed in this case, in the context of anti-TNF use, is unique. This contributes to the literature on its occurrence in the immunocompromised, in whom signs of sepsis can be masked. Nonetheless, this case demonstrates that, despite high virulence, such patients can be managed successfully with antimicrobial therapy and close monitoring.

Severe alkalosis and hypokalemia with stanozolol misuse.

Stanozolol is a popular androgenic anabolic steroid, used by body builders and athletes for physical performance enhancement. There are few data on its potential adverse effects and no documented cases of it causing severe electrolyte imbalance. Here, we report a patient presenting to a tertiary care emergency department with reduced conscious level, profound hypokalemia, and severe metabolic alkalosis, resulting from stanozolol misuse. This is the first such case reported.

The Case | Acute kidney injury after Chernobyl

A 57-year-old man was referred with a 1-month history of leg swelling, myalgia, and generalized weakness. This had been preceded by 2 weeks of sore throat, treated with aspirin and erythromycin. His past medical history included hypercholesterolemia, for which he was prescribed pravastatin. His baseline creatinine recorded 1 year previously was 90u2009μmol/l, but on this admission it was elevated at 152u2009μmol/l. He worked in the construction industry, and his occupational history was notable for having been employed extensively in Eastern Europe and Russia in the 1980s. This included close proximity to the Chernobyl Power Plant at the time of the nuclear accident in 1986.

Acute kidney injury after Chernobyl.

A 57-year-old man was referred with a 1-month history of leg swelling, myalgia, and generalized weakness. This had been preceded by 2 weeks of sore throat, treated with aspirin and erythromycin. His past medical history included hypercholesterolemia, for which he was prescribed pravastatin. His baseline creatinine recorded 1 year previously was 90u2009μmol/l, but on this admission it was elevated at 152u2009μmol/l. He worked in the construction industry, and his occupational history was notable for having been employed extensively in Eastern Europe and Russia in the 1980s. This included close proximity to the Chernobyl Power Plant at the time of the nuclear accident in 1986.

The Case |[verbar]| Acute kidney injury after Chernobyl

A 57-year-old man was referred with a 1-month history of leg swelling, myalgia, and generalized weakness. This had been preceded by 2 weeks of sore throat, treated with aspirin and erythromycin. His past medical history included hypercholesterolemia, for which he was prescribed pravastatin. His baseline creatinine recorded 1 year previously was 90u2009μmol/l, but on this admission it was elevated at 152u2009μmol/l. He worked in the construction industry, and his occupational history was notable for having been employed extensively in Eastern Europe and Russia in the 1980s. This included close proximity to the Chernobyl Power Plant at the time of the nuclear accident in 1986.

Cryptogenic colitis due to occult cytomegalovirus infection

Colitis secondary to cytomegalovirus infection is well recognised and usually straightforward to diagnose. Here two cases are reported in whom all initial investigations failed to demonstrate the presence of virus, with potential adverse consequences for its treatment. A case is made for empirical antiviral therapy despite negative investigations if clinical suspicion is high.