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P0374 CHICKENPOX IN AN ADULT: NOT ONLY A RASH
S128
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
P0374 CHICKENPOX IN AN ADULT: NOT ONLY A RASH
Elena Solla-Babío, Santiago Pintos-Martínez, Tamara Caínzos-Romero, Beatriz Buño Ramilo, Sabela Sánchez-Trigo, Pascual Sesma Sánchez. Complejo Hospitalario Arquitecto Marcide-profesor Novoa Santos. Ferrol-spain Introduction: Primary infection due to Varicella-Zoster Virus (VZV) presents in most cases as chickenpox, with a benign and self-limited course, but, when it appears in adults, it can evolves into a severe illness because of complications. A few cases of vasculitis with cerebral infarction have been described in literature as central nervous system complication during chickenpox infection Discussion: We present the case of a 42 year-old male previously healthy, whose son had chikenpox at the moment of admision. He was presented to the emergency department because of fever, rash and abdominal pain. The physical examination was relevant for fever, multiple maculopapules and vesicles in face, chest and oral mucous. The neurological examination was not relevant. The serum biochemistry values were remarkable for increased transaminases. The plain chest radiograph showed bilateral patchy alveolar infiltrates. The diagnosis was made for varicella pneumonia. A few hours later, he developed a respiratory distress, and he needed mechanical ventilation. After 15 days, a right-sided weakness, babinsky sign, dysphasia and dysphagia appeared. Cranial TC and cranial MRI were performed, showing bilateral hemispheric low density areas, related with ischemic cerebral infarction secondary to VVZ vasculitis. Lumbar puncture revealed normal cell count. Viral studies in cerebrospinal fluid (CSF) showed negative polymerase chain reaction (PCR) for virus varicella zoster DNA, and positive anti-VZV IgM antibody. Conclusions: 1.Cerebral vasculitis due to VZV primary infection is an uncommon central nervous sistem complication in adults 2.High sensibility and specificity of intrathecal anti-VZV antibodies support the diagnosis of cerebral vasculitis even in the absence of positive VZV-PCR in CSF Keywords: Vasculitis, chickenpox, VVZ, central nervous system
P0375 DRIVING ADVICE IN PATIENTS WITH THE FIRST EPILEPTIC SEIZURE/SOLITARY FIT
Kayvan Khadjooi 1 , Deepak Bhatia 2 , John Paterson 1 . 1 Department of Medicine, Scarborough General Hospital, United Kingdom; 2 Department of Medicine, Hull Royal Infirmary, United Kingdom Background: In the United Kingdom, the Driver and Vehicle Licensing Agency (DVLA) is legally responsible for deciding on medical fitness to drive. It is the duty of the licence holder or licence applicant to notify the DVLA of any medical condition which may affect safe driving and doctors should make sure that patients understand that the condition may impair their ability to drive. Doctors are advised to document formally and clearly in the notes the advice that has been given. Epileptic attacks are the most frequent medical cause of collapse at the wheel. The DVLA has detailed guidelines regarding first epileptic seizure/solitary fit, including unprovoked first solitary fit (Including seizures associated with alcohol or drug misuse) and provoked seizure. Aims: Our aim was to determine whether appropriate driving advice was given to patients admitted to the Acute Admissions Unit (AAU) with the first epileptic seizure/solitary fit. Methods: We reviewed the medical notes of patients admitted to AAU at 2 medical centres in the United Kingdom (Hull Royal Infirmary and Scarborough General Hospital) with diagnosis of first epileptic seizure/solitary fit in 12 months up to June 2008, focusing only on the emergency admission. Overall 95 notes were reviewed and 51 were excluded (e.g. known epilepsy, long-term disabilities, age<17 and death). The DVLA guidelines on first epileptic seizure/solitary fit were used as standard. Results: Total audit population was 44 with male to female ratio of 2.7:1 with the age range of 17 to 86. In 37 patients (84%) the diagnosis was unprovoked first solitary fit (including alcohol-related) and 7 patients (16%) were admitted with provoked seizure. Only 4 patients had driving status (whether the patient drives or not) documented as part of the social history. Only 11 patients (25%) received advice, of which 2 were documented both in the notes and the discharge letter, and in 9 cases it was documented only in the notes. 75% did not receive advice or if they did, it wasn’t documented. Conclusion: Of the 44 patients admitted with first epileptic seizure/solitary fit to 2 medical centres in the United Kingdom, only 25% received driving advice and only 2 patients had proper documentation. This emphasises the need for education of doctors at all levels regarding the importance of driving advice,
what the patient should be told, the importance of correct documentation and potential legal implications. Giving driving advice leaflets to patients on discharge may prove to be effective. References: www.dvla.gov.uk: At a glance guide to the current medical standards of fitness to drive (for medical practitioners). Keywords: Driving advice, first epileptic seizure, solitary fit.
P0376 TUBERCULOUS MENINGITIS: THE IMPORTANCE OF LABORATORY DATA AND IMAGING IN THE EMERGENCY ROOM
Vitor Fagundes, Inês Ferreira, Heloisa Castro, Carla Fraga, Graça Ferraz, J. Freire Soares. Centro Hospitalar Do Tâmega E Sousa, Epe - Penafiel Portugal Introduction: The tuberculous meningitis is a reality in areas where tuberculosis prevalence is still high. The diagnosis is difficult and the assumption of an adequate treatment definitely influences the prognosis. The cerebrospinal fluid has a critical value upon the diagnosis, namely the documentation of high protein value and reduced glucose, in association with a predominance of mononuclear cells. Objectives: The objective of the authors was to review the exams, made at admission to the hospital, of the patients who were discharged from the Internal Medicine Department with the diagnosis of tuberculous meningitis. Materials and methods: Retrospective study realized between the years of 2002 and 2007 in a hospital in the north of Portugal with a population area of 500.000. The data analysis was made by taking into account the clinical file and focused on the following exams: blood (leucocytes, glucose, sodium, C-reactive protein); cerebrospinal fluid (total and differential cell count, proteins, glucose, sediment stained by the Ziehl-Neelsen method, cultural test for tubercle bacilli, DNA amplification) and cerebral computed tomography (CT) scan. Results: The authors include six patients with the diagnosis of tuberculous meningitis. All of them presented a low glucose value in the cerebrospinal fluid (inferior to 50% than the serum value) and 80% of these presented a high protein value in the cerebrospinal fluid. In regard to the cell count, the medium value was 75.6±70.1/μL (in 80% of them with predominance of lymphocytes). Four patients realize cerebral CT scan without venous contrast and two patients with venous contrast. Hydrocephalia was the most common finding. Only in two patients was it possible to confirm the diagnosis by demonstrating mycobacterium tuberculosis in the cerebrospinal fluid at the emergency department. Discussion & conclusion: The suspicion of the diagnosis, together with the laboratory data (namely the cerebrospinal fluid) are of extreme relevance for the initiation of treatment directed to this entity, since the confirmation by microbiological or immunological testing has a low sensibility. Keywords: tuberculous meningitis, mycobacterium tuberculosis, cerebrospinal fluid.
P0377 ADULT STAPHYLOCOCCAL MENINGITIS: A CLINICAL COMPARISON OF STAPHYLOCOCCUS AUREUS INFECTION AND COAGULASE-NEGATIVE STAPHYLOCOCCAL INFECTION
Cristina Lopez Gonzalez-Cobos 1 , Maria Gomez Antúnez 1 , Carmen Cuenca Carvajal 1 , Maria Victoria Villalba Garcia 2 , Belen Mora Hernandez 1 , Francisco Javier Cabrera Aguilar 1 , Ana Maria Torres Do Rego 1 , Olga Marin Casajus 2 , Antonio Muiño Miguez 1 . 1 Medicina Interna 2 A; 2 Medicina Interna D. Hospital Gregorio Marañon. Madrid Introduction: Staphylococcus spp rarely cause community-acquired acute bacterial meningitis, but they are a frequent cause of nosocomial meningitis. Two different modes of pathogenesis have been described in staphylococcal meningitis: postoperative meningitis, associated with neurosurgical procedures and spontaneous meningitis, secondary to staphylococcal infection outside the central nervous system. Objectives: To describe the clinical features and outcome of staphylococcus meningitis. A comparative analysis of acute bacterial meningitis due to s aureus and coagulase-negative staphylococci in adults. Materials & methods: The charts of 27 cases of staphylococcus meningitis aged 16 or over, including those with a positive cerebrospinal fluid culture seen at one teaching hospital were reviewed. Demographic, clinical, and laboratory data, predisposing factors, source of infection and outcome were obtained. Results: The 27 staphylococcal meningitis (16 staphylococcus aureus infec-
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
P0374 CHICKENPOX IN AN ADULT: NOT ONLY A RASH
Elena Solla-Babío, Santiago Pintos-Martínez, Tamara Caínzos-Romero, Beatriz Buño Ramilo, Sabela Sánchez-Trigo, Pascual Sesma Sánchez. Complejo Hospitalario Arquitecto Marcide-profesor Novoa Santos. Ferrol-spain Introduction: Primary infection due to Varicella-Zoster Virus (VZV) presents in most cases as chickenpox, with a benign and self-limited course, but, when it appears in adults, it can evolves into a severe illness because of complications. A few cases of vasculitis with cerebral infarction have been described in literature as central nervous system complication during chickenpox infection Discussion: We present the case of a 42 year-old male previously healthy, whose son had chikenpox at the moment of admision. He was presented to the emergency department because of fever, rash and abdominal pain. The physical examination was relevant for fever, multiple maculopapules and vesicles in face, chest and oral mucous. The neurological examination was not relevant. The serum biochemistry values were remarkable for increased transaminases. The plain chest radiograph showed bilateral patchy alveolar infiltrates. The diagnosis was made for varicella pneumonia. A few hours later, he developed a respiratory distress, and he needed mechanical ventilation. After 15 days, a right-sided weakness, babinsky sign, dysphasia and dysphagia appeared. Cranial TC and cranial MRI were performed, showing bilateral hemispheric low density areas, related with ischemic cerebral infarction secondary to VVZ vasculitis. Lumbar puncture revealed normal cell count. Viral studies in cerebrospinal fluid (CSF) showed negative polymerase chain reaction (PCR) for virus varicella zoster DNA, and positive anti-VZV IgM antibody. Conclusions: 1.Cerebral vasculitis due to VZV primary infection is an uncommon central nervous sistem complication in adults 2.High sensibility and specificity of intrathecal anti-VZV antibodies support the diagnosis of cerebral vasculitis even in the absence of positive VZV-PCR in CSF Keywords: Vasculitis, chickenpox, VVZ, central nervous system
P0375 DRIVING ADVICE IN PATIENTS WITH THE FIRST EPILEPTIC SEIZURE/SOLITARY FIT
Kayvan Khadjooi 1 , Deepak Bhatia 2 , John Paterson 1 . 1 Department of Medicine, Scarborough General Hospital, United Kingdom; 2 Department of Medicine, Hull Royal Infirmary, United Kingdom Background: In the United Kingdom, the Driver and Vehicle Licensing Agency (DVLA) is legally responsible for deciding on medical fitness to drive. It is the duty of the licence holder or licence applicant to notify the DVLA of any medical condition which may affect safe driving and doctors should make sure that patients understand that the condition may impair their ability to drive. Doctors are advised to document formally and clearly in the notes the advice that has been given. Epileptic attacks are the most frequent medical cause of collapse at the wheel. The DVLA has detailed guidelines regarding first epileptic seizure/solitary fit, including unprovoked first solitary fit (Including seizures associated with alcohol or drug misuse) and provoked seizure. Aims: Our aim was to determine whether appropriate driving advice was given to patients admitted to the Acute Admissions Unit (AAU) with the first epileptic seizure/solitary fit. Methods: We reviewed the medical notes of patients admitted to AAU at 2 medical centres in the United Kingdom (Hull Royal Infirmary and Scarborough General Hospital) with diagnosis of first epileptic seizure/solitary fit in 12 months up to June 2008, focusing only on the emergency admission. Overall 95 notes were reviewed and 51 were excluded (e.g. known epilepsy, long-term disabilities, age<17 and death). The DVLA guidelines on first epileptic seizure/solitary fit were used as standard. Results: Total audit population was 44 with male to female ratio of 2.7:1 with the age range of 17 to 86. In 37 patients (84%) the diagnosis was unprovoked first solitary fit (including alcohol-related) and 7 patients (16%) were admitted with provoked seizure. Only 4 patients had driving status (whether the patient drives or not) documented as part of the social history. Only 11 patients (25%) received advice, of which 2 were documented both in the notes and the discharge letter, and in 9 cases it was documented only in the notes. 75% did not receive advice or if they did, it wasn’t documented. Conclusion: Of the 44 patients admitted with first epileptic seizure/solitary fit to 2 medical centres in the United Kingdom, only 25% received driving advice and only 2 patients had proper documentation. This emphasises the need for education of doctors at all levels regarding the importance of driving advice,
what the patient should be told, the importance of correct documentation and potential legal implications. Giving driving advice leaflets to patients on discharge may prove to be effective. References: www.dvla.gov.uk: At a glance guide to the current medical standards of fitness to drive (for medical practitioners). Keywords: Driving advice, first epileptic seizure, solitary fit.
P0376 TUBERCULOUS MENINGITIS: THE IMPORTANCE OF LABORATORY DATA AND IMAGING IN THE EMERGENCY ROOM
Vitor Fagundes, Inês Ferreira, Heloisa Castro, Carla Fraga, Graça Ferraz, J. Freire Soares. Centro Hospitalar Do Tâmega E Sousa, Epe - Penafiel Portugal Introduction: The tuberculous meningitis is a reality in areas where tuberculosis prevalence is still high. The diagnosis is difficult and the assumption of an adequate treatment definitely influences the prognosis. The cerebrospinal fluid has a critical value upon the diagnosis, namely the documentation of high protein value and reduced glucose, in association with a predominance of mononuclear cells. Objectives: The objective of the authors was to review the exams, made at admission to the hospital, of the patients who were discharged from the Internal Medicine Department with the diagnosis of tuberculous meningitis. Materials and methods: Retrospective study realized between the years of 2002 and 2007 in a hospital in the north of Portugal with a population area of 500.000. The data analysis was made by taking into account the clinical file and focused on the following exams: blood (leucocytes, glucose, sodium, C-reactive protein); cerebrospinal fluid (total and differential cell count, proteins, glucose, sediment stained by the Ziehl-Neelsen method, cultural test for tubercle bacilli, DNA amplification) and cerebral computed tomography (CT) scan. Results: The authors include six patients with the diagnosis of tuberculous meningitis. All of them presented a low glucose value in the cerebrospinal fluid (inferior to 50% than the serum value) and 80% of these presented a high protein value in the cerebrospinal fluid. In regard to the cell count, the medium value was 75.6±70.1/μL (in 80% of them with predominance of lymphocytes). Four patients realize cerebral CT scan without venous contrast and two patients with venous contrast. Hydrocephalia was the most common finding. Only in two patients was it possible to confirm the diagnosis by demonstrating mycobacterium tuberculosis in the cerebrospinal fluid at the emergency department. Discussion & conclusion: The suspicion of the diagnosis, together with the laboratory data (namely the cerebrospinal fluid) are of extreme relevance for the initiation of treatment directed to this entity, since the confirmation by microbiological or immunological testing has a low sensibility. Keywords: tuberculous meningitis, mycobacterium tuberculosis, cerebrospinal fluid.
P0377 ADULT STAPHYLOCOCCAL MENINGITIS: A CLINICAL COMPARISON OF STAPHYLOCOCCUS AUREUS INFECTION AND COAGULASE-NEGATIVE STAPHYLOCOCCAL INFECTION
Cristina Lopez Gonzalez-Cobos 1 , Maria Gomez Antúnez 1 , Carmen Cuenca Carvajal 1 , Maria Victoria Villalba Garcia 2 , Belen Mora Hernandez 1 , Francisco Javier Cabrera Aguilar 1 , Ana Maria Torres Do Rego 1 , Olga Marin Casajus 2 , Antonio Muiño Miguez 1 . 1 Medicina Interna 2 A; 2 Medicina Interna D. Hospital Gregorio Marañon. Madrid Introduction: Staphylococcus spp rarely cause community-acquired acute bacterial meningitis, but they are a frequent cause of nosocomial meningitis. Two different modes of pathogenesis have been described in staphylococcal meningitis: postoperative meningitis, associated with neurosurgical procedures and spontaneous meningitis, secondary to staphylococcal infection outside the central nervous system. Objectives: To describe the clinical features and outcome of staphylococcus meningitis. A comparative analysis of acute bacterial meningitis due to s aureus and coagulase-negative staphylococci in adults. Materials & methods: The charts of 27 cases of staphylococcus meningitis aged 16 or over, including those with a positive cerebrospinal fluid culture seen at one teaching hospital were reviewed. Demographic, clinical, and laboratory data, predisposing factors, source of infection and outcome were obtained. Results: The 27 staphylococcal meningitis (16 staphylococcus aureus infec-