Viral etiology is not uncommon among those evaluated for CNS infection in Qatar. Clinical outcomes are excellent in this group of patients. Antibiotics and acyclovir are overly used even when a viral etiology is confirmed. There is a need for clinician education regarding etiology and treatment of viral CNS infections.
We present a very rare case of concurrent empyema and liver abscess caused by Fusobacterium. Our patient presented with 3-month history of subtle abdominal discomfort and cough leading to eventually presenting with marked chest pain, dyspnoea and septic shock. CT revealed a liver abscess and large right-sided pleural effusion. Drainage of the pleural effusion yielded gross pus with the growth of Fusobacterium varium, while drainage of the liver abscess yielded Fusobacterium nucleatum. The patient responded to drainage and antibiotic therapy with resolution of symptoms and decrease in the size of empyema and abscess on follow-up imaging. We also include a review if literature of related fusobacterial infections.
Laboratory values. Cefepime, fourth-generation cephalosporin, is used for gram-negative and pseudomonal infections. It is drug of choice for febrile neutropenia. Since its approval in 1996, it has stayed on top for almost every sever gram-negative and pseudomonal infection in intensive care unit and cancer chemotherapy settings. 2 Cefepime being renally metabolized can precipitate overdose toxicity if dose is not modified in patients with endstage renal disease. Cefepime can cross blood-brain barrier. Neurotoxicity is mainly secondary to inhibitory effects of GABA-A receptors (gamma amino butyric acid-A). 3 GABA receptors are inhibitory, limiting excitation which can lead to seizures. Our patient was admitted with chest discomfort and bacterial pneumonia with right-sided pleural effusion leading to hypoxic respiratory failure. He received 2 g of leading cefepime followed by 1 g daily for 2 days before he started with altered mental status with myoclonic seizures. His mentation improved after hemodialysis.In 1996, at the time of approval of cefepime, neurotoxicity was reported as seizures in 3 patients. 4 Neurotoxicity has direct relation to plasma cefepime levels with higher levels leading to neurotoxicity. 5 Cefepime crosses bloodbrain barriers. Most common neurotoxic presentation is altered level of consciousness, delirium, and myoclonus (80%, 47%, and 40%, respectively) as per a care review published. 1 Neurotoxicity has been reported in 15% of intensive care unit as per Payne et al. 6 Our patient had an episode of myoclonic seizure which was documented by electrocardiogram and was in altered mental status. Convulsive or nonconvulsive status epilepticus can also be another presentation. 1 Electrocardiogram can be helpful in diagnosing. The Naranjo score was 11 for this patient. 7 Treatment is stopping the antibiotic. Antiepileptic medication such as levetiracetam, valproic acid, and benzodiazepines can be used. Our patient was started on levetiracetam. He had no further episodes of seizures after hemodialysis and after cefepime was stopped. Patient was given couple secession of hemodialysis which improved his mentation.
To examine the impact of CYP2C19 genotype on selective serotonin reuptake inhibitor (SSRI) prescribing patterns. Patients & methods: Observational cohort containing 507 unique individuals receiving an SSRI prescription with CYP2C19 genotype already in their electronic medical record. Genotype was distributed as follows: n = 360 (71%) had no loss of function alleles, 136 (26.8%) had one loss of function allele and 11 (2.2%) had two loss of function alleles. Results & conclusion: For poor metabolizers exposed to sertraline, citalopram or escitalopram, providers changed prescribing patterns in response to alerts in the electronic medical record by either changing the drug, changing the dose or monitoring serial EKGs longitudinally. For intermediate metabolizers exposed to sertraline, citalopram or escitalopram, no alert was needed (mean QTc = 440.338 ms [SD = 31.1273] for CYP2C19*1/*1, mean QTc = 440.371 ms [SD = 29.2706] for CYP2C19*1/*2; p = 0.995).
We present a case of right sided chylothorax in the setting of cirrhosis believed to be secondary to extensive venous thromboembolism of the left upper extremity and exacerbated by chylous ascites. Our patient responded to conservative management with anticoagulation and a repeat thoracentesis revealed transformation of the fluid back to straw coloured transudate. We also include a brief discussion of the diagnosis and management of chylothorax.
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