An 82-year-old man with a history of end-stage renal disease presented with progressively worsening confusion and somnolence for the past 4-5 days. The patient was diagnosed with herpes zoster by his primary care physician 5 days ago and was started on a course of valacyclovir 1 g three times a day (dose not adjusted for renal impairment).A lumbar puncture was performed and cerebrospinal fluid (CSF) studies revealed 37 white blood cells (WBCs)/hpf (100% monocytes), protein 64 mg/dL and glucose 52 mg/dL. He was started on ceftriaxone, ampicillin and acyclovir. MRI of the brain was done and was unremarkable. Acyclovir-induced encephalopathy was high on differential, but his CSF findings were concerning for viral encephalitis. Nonetheless, all antimicrobials were discontinued and he was scheduled for a 5-hour dialysis session. The very next day, he showed immense improvement and eventually recovered completely. CSF PCR tests for both herpes simplex virus and varicella zoster virus came back negative.

Level of Evidence: V, Expert Opinion

The Ionising Radiation (Protection of Persons Undergoing Medical Examination or Treatment) Regulations 1988 (POPUMET) made it compulsory from June 1990 for all staff directing medical exposures to ionising radiation to receive formal tuition at a core knowledge course. This course described the hazards of ionising radiation and the safe use of x-ray equipment. It instructed on the nature of ionising radiation and its interaction with tissues, principles and means of dose reduction to patient and operator, the importance of using the patient’s existing radiological information and statutory responsibilities. The POPUMET course was discontinued following the Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R). IR(ME)R training for healthcare professionals is available as a half-day theoretical course suitable for those designated as ‘referrer’ by their employers. Other locally run ionising radiation protection courses are tailored to the varied requirements of a spectrum of healthcare professionals.

Canine heartworm, Dirofilaria immitis, is a nematode parasite that infects dogs by way of mosquito bite. Rarely, humans play accidental hosts to this parasite and are not a suitable environment for the nematode to live. As the parasite dies in the pulmonary vessels it embolizes the vessels causing infarction and eventual nodule formation in the lungs. In the right clinical context, a nodule can be considered malignant prompting invasive tissue sampling. We describe a case of a 48-year-old man who was found to have multiple asymptomatic scattered pulmonary nodules during imaging workup for an insulinoma. Fine needle biopsy of the largest nodule revealed a necrotic granuloma, lab testing and culture ruled out fungal and bacterial causes. Clinically, this picture was consistent with D. immitis infection.