Malur Sudhanva

UK hantavirus, renal failure, and pet rats

In November, 2012, a 28-year-old man, presented with a 4-day history of fever, shivers, sweating, and vomiting. He had type-2 diabetes, which was being treated with sitagliptin and metformin. On admission he had evi dence of a systemic infl ammatory response (temperature 39·3°C, pulse 160 bpm, respiratory rate 30 per min, white cell count 15·0×10⁹ per L, with 12·3 neutrophils and 0·2 mye locytes), abnormalities of blood clotting (INR 1·6, PTT 57 s, fi brinogen 0·99 g/L (normal range 1·5–4·5); plate lets 19×10⁹ per L), multi-organ failure (creatinine 167 μmol/L, raised alanine aminotransferase 511 U/L and bilirubin 87 μmol/L), progressive hypoxia, hyperglycaemia glucose 20·6 mmol/L), and lactic acidosis (PH 7·29, lactate 7·5 mmol/L). He was diagnosed with overwhelming sepsis and transferred to the intensive care unit. Initial treatment was with piperacillin-tazobactam, insulin, oxygen, and aggressive fl uid replacement, including platelet infusions, fresh frozen plasma, and cryo-precipitate. Ventilatory support was required 15 h after admission, at which time he was anuric. Renal replace-ment therapy was needed for 21 days and ventilatory support for 38 days, partly because of pseudomonas superinfection of the chest that was diagnosed on day 17.Tests for legionella and leptospira and initial blood cultures were negative. Serum taken 30 days after admission had a high IgG titre to Seoul hantavirus (1:10 000 by IFA, Euroimmun, Medizinische Labor-diagnostika AG), although serum from 1 month before admission (sent for hepatitis screening because of a mild transaminasaemia) was negative. Hantavirus RNA was not detected in either sample. We learnt that he kept two pet agouti rats (

Adenovirus urethritis and concurrent conjunctivitis: a case series and review of the literature

We present eight cases and review the literature of concurrent urethritis and conjunctivitis where adenovirus was identified as the causative pathogen. The focus of this review concerns the identification of specific sexual practices, symptoms, signs and any serotypes that seem more commonly associated with such adenovirus infections. We discuss the seasonality of adenovirus infection and provide practical advice for clinicians to give to the patient.

A man who vomited until he couldn't walk

In January, 2010, a 73-year-old man became acutely unwell with a sore throat, unsteadiness, and vomiting while visiting Bhopal, India. Within 12 hours he was unable to stand. He was admitted to a local hospital, where he was noted to have a fl accid tetraparesis. A CSF sample showed raised protein (790 mg/L) and presence of white blood cells (lymphocytes 4, polymorphonuclear cells 3), but no glucose and no organisms on Gram stain or stain for acid-fast bacilli. He was transferred to a tertiary centre in Mumbai where a tracheostomy was done and MRI of the brain showed acute encephalomyelitis of the pons, medulla, and upper cervical cord. He was given intravenous methylprednisolone for 7 days, and then oral prednisolone 60 mg/day. He did not improve and on Feb 6, 2010 was started on a 5 day course of intravenous immunoglobulin. On Feb 24, 2010 he was transferred to London for continuing management. On admission to our hospital, he was alert, with a Glasgow Coma Scale score of 10T. Cranial nerve examination was unremarkable, but he had fl accid muscle tone with Medical Research Council (MRC) grade 0/5 power, and absent refl exes in upper and lower limbs. Sensory examination was normal. He was treated empirically for a bacterial encephalo menin gitic brainstem infection with ceftri axone and amoxicillin, and had a repeat MRI of his brain and cervical cord (fi gure A). Laboratory tests were normal. Follow-up CSF analysis showed white blood cells within normal range, protein 201 mg/L, and glucose 5·1 mmol/L (serum 6·1 mmol/L). Gram stain and tests for oligoclonal bands were negative. CSF was also negative for herpes simplex virus 1 and 2, varicella zoster virus, Ebstein-Barr virus, and enterovirus. Repeat MRI showed residual medullary high T2 signal with cervical cord extension, which was reduced from previous imaging and thought to be infl am matory (fi gure B). Neurophysi ology was done because of persisting fl accid paralysis suggesting periph eral neur opathy or anterior horn disease. Widespread denervation was found and we considered a viral anterior horn myelitis. Type specifi c serology for polioviruses showed past but not recent exposure. Serum taken in March, 2010 was positive by EIA for West Nile virus IgM and IgG, but CSF from the Lancet 2012; 380: 1966

Lymphadenopathy and splenomegaly in an HIV-infected man.

South London Specialist Virology Centre, King’s College Hospital, Denmark Hill, London SE5 9RS, United Kingdom Virus Reference Department, Microbiology Services Colindale, 61 Colindale Avenue, London NW9 5HT, United Kingdom Department of Histopathology, King’s College Hospital, Denmark Hill, London SE5 9RS, United Kingdom Department of HIV/Genitourinary Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, United Kingdom Department of Haematological Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, United Kingdom