Study objectives Hypoglycorrhachia (CSF glucose < 45mg/dL) has been identified as a prognostic factor in patients with meningitis. We analyzed the differential diagnosis of hypoglycorrhachia and its clinical significance. Methods Retrospective study of 620 adult patients with community acquired meningitis [CSF WBC >5 cells/mm3, absence of a CSF shunt or recent neurosurgical procedure (< 1 month)] at 8 Memorial Hermann Hospitals in Houston, TX from January, 2005 to December, 2010. An adverse clinical outcome was defined as a Glasgow outcome scale of 4 or less. Results Out of 620 patients with meningitis, 116 (19%) had hypoglycorrachia. Etiologies of hypoglycorrhachia were idiopathic (40), bacterial (27), cryptococcal (26), viral (15), and tuberculous (4). Patients with hypoglycorrachia were more likely to be immunosuppressed, have a history of intravenous drug use, and present with a vesicular or petechial rash, nausea or vomiting, nuchal rigidity, sinusitis/otitis, abnormal mental status and focal neurological deficits compared to those patients without hypoglycorrachia (p<0.05). Additionally, patients in the hypoglycorrhachia group had significantly higher rates of positive CSF and blood cultures, urgent treatable conditions and abnormal cranial imaging (p<005). Furthermore, patients with hypoglycorrachia had more adverse clinical outcomes [26 out of 116 (22.4%) vs. 45 out of 504 (8.9%)] (p< 0.001). Conclusion Hypoglycorrhachia has significant clinical and prognostic value in the evaluation of adult patients with community-acquired meningitis.
h Paraconiothyrium cyclothyrioides is a recently described coelomycetous fungal species. We present a case in a renal transplant patient with chronic skin lesions of the lower extremities caused by P. cyclothyrioides. Treatment with posaconazole led to complete resolution of the lesions. P. cyclothyrioides should be considered an opportunistic human pathogen in immunocompromised patients. CASE REPORTA 49-year-old Latin American man with end-stage renal disease and a cadaveric renal transplant (2 years prior to the current admission) was hospitalized with cutaneous lesions in his lower extremities. The patient had history of type II diabetes, hypertension, and atrial fibrillation. One and half years previous to admission, the patient received thymoglobulin for acute T-cell rejection, with improvement of the episode. Approximately 6 months before the current admission, the patient first noticed a painless, nonpruritic, mildly tender scaly papule on the left tibia just inferior to the knee joint and applied a local adhesive band to prevent friction injury. Over the next few months, other lesions appeared on both tibial surfaces which then began to coalesce into violaceous, necrotic, plaque-like lesions with some areas of ulceration and crusting and mild self-limiting sanguineous discharge without accompanying fevers. The patient lives in Brownsville, TX, works in an office as a manager, and denied any travel outside Texas, trauma, or animal or insect bites. The patient's hobbies include performing mechanical work on car engines. Medications included leflunomide, prednisone, tacrolimus, doxazosin, clonidine, carvedilol, minoxidil, amlodipine, trimethoprim-sulfamethoxazole, insulin, famotidine, gemfibrozil, and pravastatin. His complete blood count was notable for a platelet count of 73 and creatinine of 2.4 mg/dl. On physical examination, he was afebrile and vital signs were stable. A cardiac examination evidenced an irregular rate and a II/VI murmur loudest in the apex. The lungs were clear, and the rest of the examination was unremarkable except for the lower extremities. He had a crusted, ulcerated plaque on the anteromedial aspect of the left knee (measuring 6 by 3 cm) and several similar-appearing lesions of smaller size on the same area (Fig. 1A). The patient was started on vancomycin (1.25 g every 24 h); radiographs of the knee did not reveal any bone abnormality. A skin biopsy specimen yielded a presumptive diagnosis of pyoderma gangrenosum, antibiotics were stopped, and the patient was discharged with wound care instructions and silver sulfadiazine.Two months prior to the current admission, a fungal culture from the skin tissue was positive for a single mold which grew on Sabouraud dextrose (Sab Dex) agar but was not identified at the time. Oral voriconazole (200 mg orally every 12 h) administration was initiated. A month after his discharge, he presented to the dermatology clinic with evidence of progression of his skin lesions and was again admitted to the hospital. He denied new recent trauma or travel h...
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