Pericarditis, usually viral in origin, is an infrequent cause of chest pain. Pericarditis due to drug allergy is even less frequent and is thus rarely considered in the diVerential diagnosis. A case is reported of a woman who presented with severe chest pain, caused by minocycline induced pericarditis. Such allergy may be more common than reported. It is suggested that drug induced pericarditis should be included in the diVerential diagnosis of acute chest pain. (Postgrad Med J 2000;76:420-422) Keywords: chest pain; pericarditis; minocycline; drug allergy Chest pain is a frequent cause of acute hospital admission. Demographic factors, duration, exercise relation and site of the pain, associated symptoms, and the electrocardiogram (ECG) are all helpful in establishing the diagnosis. However it is often forgotten that adverse drug reactions can cause chest pain and a full drug history is vital. Here we present a case of pericardial pain due to an adverse reaction to an antibiotic taken for acne. Case reportA 42 year old woman with longstanding acne was started on minocycline three weeks before presentation. After two weeks' treatment she developed low grade fever, cough, and dyspnoea. She was admitted to another hospital where no clear diagnosis was made. A chest x ray film at this time was normal. After two days' observation, during which she remained afebrile, she was discharged home. Shortly thereafter she developed moderately severe anterior chest pain, related both to deep inspiration and to position, and her general practitioner arranged emergency admission. On examination she was in moderate discomfort, with no abnormal cardiovascular signs. No pericardial or pleural rub was heard. A chest x ray film and an isotope ventilationperfusion scan were normal. Her ECG was very abnormal (fig 1), and the pattern of the abnormality was not typical for pericardial disease and raised the possibility that she might have a coronary or myocardial problem. Cardiac ultrasound showed vigorous left and right ventricular function, with normal myocardial density, and no evidence of pericardial disease. Cardiac enzymes (including creatine kinase) were not raised. A blood count showed marked eosinophilia, with an absolute eosinophil count of 13 000 × 10 9 /l. Though it was considered likely that minocycline had induced the eosinophilia which in turn had led to pericardial inflammation, the ECG was so worrying that it was felt appropriate to undertake coronary angiography. This revealed normal coronaries. Computed tomography of the thorax showed no evidence of pneumonitis. Once minocycline was discontinued her eosinophil count fell rapidly, her chest pain resolved, and at follow up six weeks later her ECG had returned to normal. The final diagnosis was minocycline induced eosinophilic pericarditis. DiscussionThis patient presented with pleuritic chest pain and a dramatically abnormal ECG, which resolved on discontinuing minocycline. The chest pain was consistent with pericarditis, the ECG was typical for stage III of a...
There have been few studies investigating the use of GLP‐1 agonists in patients with insulin‐treated type 2 diabetes and none looking at the costing. We compared the efficacy and relative cost of adding exenatide treatment to patients with type 2 diabetes receiving either oral hypoglycaemic agents (OHAs) or insulin.Patients were recruited from West Suffolk Hospital Diabetes Centre. Data were acquired retrospectively from 207 patients completing six months of treatment.Of 207 patients, 188 demonstrated good clinical progress with a mean HbA1c reduction of 1.6% (p<0.0001) and weight loss of 6.9kg (p<0.0001). Nineteen patients discontinued exenatide as HbA1c reduction did not achieve the NICE target (0.4%; p=0.29), but they did achieve significant weight loss (5.6kg; p<0.0001). The 188 patients continuing on exenatide were sub‐divided into insulin‐treated (n=88) or tablet‐treated (n=100). At six months, tablet‐treated patients achieved an HbA1c reduction of 1.6% (p<0.0001) and weight loss of 6.5kg (p<0.0001). Insulin‐treated patients achieved similar results: HbA1c reduction 1.6% (p<0.0001), weight loss 7.3kg (p<0.0001). After six months of exenatide treatment, the mean reduction in daily insulin dose was 48 units/person in the insulin‐treated group. In the tablet‐treated group, the cost of diabetic medication (per person/month) after six months was £54.90 above baseline, whereas in the insulin‐treated group this was only £36.20 above baseline, because the reduction in insulin dose offset the cost of exenatide.It was concluded that exenatide is clinically effective in both insulin‐treated and tablet‐treated type 2 diabetes, but is more cost effective in those originally treated with insulin. Copyright © 2011 John Wiley & Sons.
A 60-year-old woman, who had been taking lithium for 36 years for bipolar affective disorder, was referred to an endocrinologist by her psychiatrist for investigation of polydipsia and polyuria. Water deprivation did not concentrate her urine, nor did desmopressin, indicating the diagnosis of nephrogenic diabetes insipidus (NDI). She was started on chlorthalidone, a treatment for NDI, and her symptoms improved dramatically. Her polyuria was well controlled on chlorthalidone for 4 years, until she started feel tired and weak and her polyuria worsened. Initially these symptoms were attributed to her depression and lithium therapy. However, routine blood testing revealed a random blood glucose of 18.5 mmol/litre, thereby confirming the diagnosis of type 2 diabetes, and a corrected calcium of 3.02 mmol/litre (normal range 2.1–2.6 mmol/litre). She was started on a diabetic diet, resulting in good diabetes control (confirmed by haemoglobin A1c) and her symptoms improved. The patient's chlorthalidone was stopped as thiazide diuretics can cause hypercalcaemia and her calcium was repeated. The repeat value was higher at 3.07 mmol/litre and her parathormone was alsoelevated at 11.24 pmol/litre, confirming hyperparathyroidism. A parathyroid adenoma was sought but a nuclear medicine scan (Tc99m ssesta-MIBI; technetium 99m-sesta 2-methoxy isobutyl isonitrille) and ultrasound examination of the neck failed to localize an adenoma. It was felt that she had developed parathyroid hyperplasia secondary to chronic lithium therapy (Mallette and Eichhorn, 1986), so her lithium was withdrawn and replaced with sodium valproate. Her NDI and hyperparathyroidism resolved on withdrawal of lithium.
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