West Nile Virus (WNV) is a mosquito-borne flavivirus, which has been known to cause human infection in Africa, the Middle East, and southwestern Asia. It has also been isolated in Australia and sporadically in Europe but never in the Americas. Clinical features include acute fever, severe myalgias, headache, conjunctivitis, lymphadenopathy, and a roseolar rash. Rarely is encephalitis or meningitis seen. During the month of August 1999, a cluster of 5 patients with fever, confusion, and weakness were admitted to the intensive care unit of the same hospital in New York City. Ultimately 4 of the 5 developed flaccid paralysis and required ventilatory support. Three patients with less-severe cases presented shortly thereafter. With the assistance of the New York City and New York State health departments and the Centers for Disease Control and Prevention, these were documented as the first cases of WNV infection on this continent.

Objective Although most cases of swine-origin influenza A (H1N1) virus (S-OIV) have been self-limited, fatal cases raise questions about virulence and radiology's role in early detection. We describe the radiographic and CT findings in a fatal S-OIV infection. Conclusion Radiography showed peripheral lung opacities. CT revealed peripheral ground-glass opacities suggesting peribronchial injury. These imaging findings raised suspicion of S-OIV despite negative H1N1 influenza rapid antigen test results from two nasopharyngeal swabs; subsequently, those results were proven to be false-negatives by reverse transcriptase polymerase chain reaction. This case suggests a role for CT in the early recognition of severe S-OIV.

Viruses cause most forms of encephalitis. The two main types responsible for epidemic encephalitis are enteroviruses and arboviruses. The City of New York reports about 10 cases of encephalitis yearly. Establishing a diagnosis is often difficult. In August 1999, a cluster of five patients with fever, confusion, and weakness were admitted to a community hospital in Flushing, New York. Flaccid paralysis developed in four of the five patients, and they required ventilatory support. Three, less severe, cases presented later in the same month. An investigation was conducted by the New York City (NYC) and New York State (NYS) health departments and the national Centers for Disease Control and Prevention (CDC). The West Nile virus (WNV) was identified as the etiologic agent. WNV is an arthropod‐borne flavivirus, with a geographic distribution in Africa, the Middle East, and southwestern Asia. It has also been isolated in Australia and sporadically in Europe but never in the Americas. The majority of people infected have no symptoms. Fever, severe myalgias, headache, conjunctivitis, lymphadenopathy, and a roseolar rash can occur. Rarely, encephalitis or meningitis is seen. The NYC outbreak resulted in the first cases of WNV infection in the Western Hemisphere and the first arboviral infection in NYC since yellow fever in the nineteenth century. The WNV is now a public health concern in the United States.

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The case is reported of a yoga practitioner who, during an exacerbation of asthma, developed a substantial increase in serum muscle enzymes. This was related to his yoga breathing exercises, which he used to enhance the delivery of aerosolised bronchodilators. As his condition improved and the use of these yoga manoeuvres diminished, the muscle enzyme levels fell to normal.Mild to moderate increase in serum creatine kinase and other muscle enzyme activities have been reported with both acute and chronic asthma,'-3 and independently with the regular practice of yoga.45 Substantial increases in muscle enzymes have not been reported in either of these conditions alone or in combination. Case reportsA 63 year old yoga enthusiast with a two year history of asthma was admitted with shortness of breath and wheezing of one week's duration. His asthma had been well controlled with oral theophylline (300 mg thrice daily), salbutamol tablets (8 mg thrice daily), and a beclomethasone inhaler. He claimed that yoga breathing exercises usually alleviated mild attacks of wheezing. On this occasion, however, the exercises were not effective.Physical examination showed laboured breathing at 32 breaths a minute, a hyperresonant chest, and bilateral diffuse wheezing.The initial peak expiratory flow (PEF) was 450 1/min, whereas he knew his usual value to be 800 1/min. Arterial blood gas analysis when he was breathing 2 1/min of oxygen by nasal cannula showed a pH of 7 45, an arterial carbon dioxide tension of 4-4 kPa, and an arterial oxygen tension of 7-6 kPa. The chest radiograph was normal. An electrocardiogram showed sinus tachycardia and was unchanged from the previous one.Treatment for asthma was begun with an aminophylline infusion, methylprednisolone, nebulised orciprenaline, and oral salbutamol.On admission serum creatine kinase activity was 777 IU/1, lactic dehydrogenase 207 IU/1, aspartate aminotransferase 37 Address for correspondence: Dr Frank M Tamarin, Division of Pulmonary Diseases, New Rochelle Hospital, New Rochelle, New York, USA. Reprints will not be available. Accepted 23 March 1988 IU/1, and aldolase 49 U/I (normal < 8 U/1). Creatine kinase activity continued to rise and peaked on the second day with a value of 2273 IU/I (figure). Isoenzyme analysis showed the creatine kinase and lactic dehydrogenase to originate only from skeletal muscle. Tests for serum rheumatoid factor and antinuclear antibody gave negative results and the urine was free of myoglobin. Creatinine clearance was 99 ml/min. The results of thyroid function tests and the erythrocyte sedimentation rate were normal. The peak flow increased to 550 1/min by the fourth hospital day.The origin ofthe increased serum muscle enzyme activities was not clear in the absence of muscle pain, seizure activity, and trauma. When specifically questioned about vigorous physical activity the patient denied conventional exercise but demonstrated his yoga breathing manoeuvres, which consisted offorceful repetitive undulating movements, beginning in the legs...

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A case of a young user of Thermadrene (SportPharma USA, Inc, Concord, Calif), an herbal remedy for weight loss, was studied. We believe that Thermadrene can cause serious complications such as ischemic stroke. Because these remedies are available over the counter and are not regulated by the Food and Drug Administration or similar organizations, there is a need for critical scrutiny of their content and side effects, as is performed for other pharmaceuticals.