BackgroundEosinophilic granulomatosis with polyangiitis is a complex multisystemic syndrome with heterogeneous presentation. Most often, there is a clinical history of asthma or other atopic conditions, and current presentation generally includes signs of cutaneous or pulmonary involvement. Very few reports described myalgia or weakness as the chief complaint. Of these, only a few included muscle biopsy evaluation and none showed convincing evidence of primary myositis. We believe this report is the first to demonstrate true myositis in the setting of early eosinophilic granulomatosis with polyangiitis.Case presentationThis report describes a 74 year old Caucasian man, with no known allergies, presenting severe myalgia, muscle weakness, jaw claudication, and fever. Blood work showed marked eosinophilia and high creatine kinase levels. Biceps brachialis muscle biopsy revealed eosinophilic necrotizing vasculitis and true myositis with myophagocytosis of non-necrotic fibers and strong sarcolemmal MHC-1 overexpression by immunohistochemistry. This patient was successfully treated with prednisone and azathioprine.ConclusionOur finding of true myositis in a case of eosinophilic granulomatosis with polyangiitis suggests that primary auto-immunity against muscle fibers, distinct from the secondary effects of vasculitis, can occur in this entity and may represent an overlap syndrome. Early recognition of eosinophilic granulomatosis with polyangiitis in patients presenting with myositis may provide an opportunity to treat the vasculitis before onset of severe multisystemic disease. We recommend the use of muscle biopsy with immunohistochemistry for MHC-1 to confirm the diagnosis of myositis in the setting of eosinophilic granulomatosis with polyangiitis.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2474-15-388) contains supplementary material, which is available to authorized users.

BackgroundThe use of magnetic resonance imaging (MRI) seems to be increasing in patients with gonalgia. Findings such as osteoarthritis and meniscal damages are very prevalent in older patients, often simultaneously [1–3]. These findings are of undetermined significance, as invasive therapeutic procedures provide no additional benefit [4].ObjectivesThe aim of this study is to analyze MRI indications and clinical impact in this population in our center.MethodsWe retrospectively analyzed 215 medical records of patients older than 50 yo having undergone a knee MRI in 2009. Medical charts were reviewed up to 2014 for: patient characteristics, MRI indication, ordering physician specialty, radiography prior to MRI, MRI findings and clinical impacts of the MRI.ResultsPatient's average age was 60.6±7.5. Main MRI indications were meniscopathy: 148 (68.8%) and chronic pain: 92 (42.8%). Most MRIs were ordered by general practitioners (GP): 148 (68.8%) and orthopedic surgeons (OS): 55 (25.6%). Chronic pain investigation was significantly higher in GPs than in OS (48.0% vs 27.3%, p=0.008). Findings show that 185 (86%) patients had osteoarthritis (OA) and 170 (79.1%) had meniscal lesions. Overall, 87 (40.5%) patients were seen by an OS and 27 (31%) of them underwent an invasive intervention. Among the 81 patients with moderate-to-severe OA on MRI, 36 (46%) had evidence of moderate-to-severe OA on a previous plain radiography, 28 (34.6%) were seen by an OS, and 3 (3,7%) underwent a meniscectomy.ConclusionsOur study reproduces the known association between OA and degenerative meniscal changes in older patients. About half of our cohort could have been appropriately diagnosed and treated based on available radiographic information, thus avoiding the MRI and subsequent OS evaluation. Meniscectomy - an MRI dependent procedure - was rare, particularly in patients with advanced OA. Educational and pragmatic measures must be emphasized to limit the inappropriate use of this costly imaging modality.ReferencesBoden SD, Davis DO, Dina TS, Stoller DW, Brown SD, Vailas JC, et al. A prospective and blinded investigation of magnetic resonance imaging of the knee. Abnormal findings in asymptomatic subjects. Clin Orthop Relat Res. 1992 Sep;(282):177–85.Kornick J, Trefelner E, McCarthy S, Lange R, Lynch K, Jokl P. Meniscal abnormalities in the asymptomatic population at MR imaging. Radiology. 1990 Nov;177(2):463–5.Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S, et al. The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone Joint Surg Am. 2003;85-A:4–9.Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675–84.Disclosure of InterestNone declared

The Bezold-Jarisch reflex is a parasympathetic reflex induced by intense mechanical stimulation of the ventricular myocytes. Exceptionally, cases have been described in patients receiving dobutamine infusion during a stress echocardiography. All were healthy middle-aged women and recovered without sequelae. A healthy 60-year-old woman suffered two 5.9-second episodes of asystole during her 20 mcg/kg/min infusion of dobutamine. Recovery was quick and without sequelae. Echocardiography and coronary angiography were both normal. In conclusion, this is the fourth documented case of a severe Bezold-Jarisch reflex causing asystole during dobutamine infusion. Diagnosis can only be made after excluding all other possible diagnoses, most importantly ischemia. This serves as a reminder of the importance of close monitoring during dobutamine infusion.

To present an unrecognized vascular complication of bacillus Calmette-Guérin (BCG) therapy administered for superficial bladder carcinoma. We also review the potential mimickers for primary angiitis of the central nervous system (PACNS) as well as complications of intravesical BCG therapy. An 89-year-old Caucasian man with a history of relapsing high-grade bladder carcinoma treated with intravesical BCG presented with recurring episodes of right upper limb paresthesia with clumsiness and dysarthria. Magnetic resonance imaging of the head revealed multiple predominantly left-sided frontotemporal micronodular peri-vascular lesions. Left frontal lobe biopsy showed non-necrotizing granulomatous vasculitis. Ziehl staining was negative. Initially, he was treated for PACNS but his symptoms relapsed during every attempt to taper the corticosteroids. Six months later, he developed bilateral mycobacterial endophthalmitis, caused by Mycobacterium bovis. Brain biopsy was reviewed and confirmed the presence of perivascular mycobacteria. A retrospective diagnosis of BCG-induced central nervous system vasculitis was made and he was treated with high-dose corticosteroids, moxifloxacin, isoniazid, ethambutol, and rifampicin. BCG is a live attenuated form of Mycobacterium bovis widely used as tuberculosis vaccination and intravesical therapy for superficial forms of bladder cancer. Systemic complications affect roughly 5% of patients and can manifest months or years after the last instillation. Cases of endophthalmitis, meningitis, aortitis, or mycotic aneurysms have been described, but no reports of CNS vasculitis have been found. In disseminated forms of BCG infections, referred to as BCGitis, histopathology usually reveals granulomatous inflammation. Mycobacterial cultures are often negative, making this a diagnostic challenge. This is the first documented case of BCG-induced small-vessel CNS vasculitis. Mycobacterium bovis infection is rare and findings are often nonspecific, making the diagnosis very difficult. Other infectious and non-infectious causes must be ruled out appropriately before considering this entity.