Conjunctival vascular tortuosity was the most common manifestation in this series. Conjunctival and retinal vessel tortuosity, and corneal verticillata are frequently observed in Fabry disease. The incidence of lenticular changes is not consistently reported, but in this series and many others, it is much less common than that of corneal, conjunctival and retinal changes.
Symptoms of anhydrosis, acroparaesthesiae, rash and renal disease suggest diagnosis of Fabry's. Women are commonly symptomatic, and the advent of therapy highlights the practical advantage of earlier diagnosis.
The data reviewed present a case for increasing the dose of clozapine in non-responsive patients to achieve a plasma level of at least 350-420 ng mL-1. Non-response at these levels, however, should not preclude a further upward titration of dose. This should occur unless (i) clinical response is obtained at a lower dose, (ii) intolerable side effects occur, or (iii) a daily dose of 900 mg is reached.
The data reviewed present a case for increasing the dose of clozapine in non-responsive patients to achieve a plasma level of at least 350-420 ng mL-1. Non-response at these levels, however, should not preclude a further upward titration of dose. This should occur unless (i) clinical response is obtained at a lower dose, (ii) intolerable side effects occur, or (iii) a daily dose of 900 mg is reached.
We report on a case of recurrent bacteremia due to three Bacillus spp. in an immunocompetent patient with no history of intravenous drug use. The source of the organisms was postulated to be a self-injected compound containing Bacillus spores, given the patient's past history of psychiatric illness and self-destructive behavior. CASE REPORTAn 18-year-old female presented to our emergency department with a 6-h history of an acute onset of a retro-orbital headache, a nonproductive cough, and poorly localized abdominal pain. Three weeks earlier the patient had been briefly hospitalized at the same institution for an episode of enteroviral meningitis.On examination, she was afebrile, had no signs of meningism, and had no focal neurology. Cardiorespiratory and abdominal examinations were normal. She was admitted to a hospital ward for further evaluation and observation.Twelve hours later she became febrile (39°C), tachycardic (180 beats/min), and hypotensive (systolic blood pressure, 85 mm/Hg). Her white blood cell count and C-reactive protein (CRP) level rapidly became elevated, and the results of liver function tests became abnormal. A chest X ray was normal, and a computed tomography scan of her abdomen and pelvis revealed a small amount of free fluid in the pelvis, with a normal pancreas and liver. Because an abdominal focus was suspected, the patient was treated empirically with ampicillin, gentamicin, and metronidazole. Six sets of cultures of blood collected at this stage grew three Bacillus species that were identified as Bacillus licheniformis, Bacillus pumilus, and Paenibacillus polymyxa (formerly Bacillus polymyxa). Once these blood culture results were known, the antibiotic regimen was changed to vancomycin, ciprofloxacin, and metronidazole.After the commencement of intravenous antibiotic treatment, the patient rapidly became afebrile, followed by normalization of her inflammatory markers over the ensuing 72 h. However, she continued to complain of epigastric pain and exhibited mild epigastric tenderness but had no clinical evidence of peritonitis. A gastroscopy performed at this stage revealed no abnormality. Three further sets of cultures of blood collected after 9 days of treatment were negative. After 15 days of treatment, vancomycin was withdrawn, and ciprofloxacin and metronidazole were continued. On the day that vancomycin treatment was ceased, the patient again became febrile, with hypotension, tachycardia, and an elevation in CRP levels and the white blood cell count. Blood cultures performed at this time once again grew B. pumilus. Vancomycin was reintroduced.Following her second febrile episode, the patient was queried about potential self-induced medical illness (Munchausen's syndrome). She angrily denied any past psychiatric history and repeatedly threatened discharge against medical advice. At this stage, her parents reported finding some bloodstained bandages and syringes in her room at home. No illegal recreational drug substances were found. However, for ethical reasons a search of her ho...
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