498 Abstracts

stressed that even if this advice is followed invasive mono-microbial necrotizing fasciitis due to Pseudomonas aerugi-nosa can still be rapidly fatal as seen in our patient.

BRAIN HAEMORRHAGE IN A YOUNG ADULT

Linsey BatchelorSouthern General Hospital, Glasgow, United Kingdom

Introduction

A 34 year old man was brought to hospital by ambulancehaving suffered an episode of severe confusion and agita-tion at home. The patient had a past history of intravenousdrug abuse. He was on the methadone program and until 2weeks previously, he had abstained from injecting heroinfor 3 years. He also occasionally used cocaine and di-azepam. There was no other past medical history of note.His partner recounted that he had complained of anincreasingly worsening headache over the preceding36 hours and had become agitated over the last 7 hours.This agitation intensi fied until he was thrashing aroundhis bedroom, banging on walls, and verbalising nonsense.

Scienti fic findings

On arrival at the Emergency Department his GCS was 7 andother observations were as follows: temperature 36.7 �C,heart rate 140 bpm, blood pressure 140/80mmHg, respira-tory rate 40. He was very difficult to assess due to extremeagitation and he was anaesthetised and intubated after suf-fering a tonic-clonic seizure. A CT scan revealed a very ab-normal appearance to the brain with severe swelling andsignificant bleeding into the sub-arachnoid space. Blood re-sults were as follows: haemoglobin 228 g/l, plate- lets77x109/l, white cell count 10.6x109/l, CRP 21 mg/l, PT ratio1.63, APTT ratio 2.29, fribrinogen 0.8 g/l, essentially nor-mal U&Es, and mildly deranged LFTs.

Discussion

The patient’s condition rapidly deteriorated, and despiteattempts at resuscitation in intensive care, he died 12 hoursafter admission. The cause of death was determined atpost-mortem. This case highlights an unusual presentationduring a recent outbreak and will be compared to the otherpresentations seen at that time.

Conclusions

This was one of the first cases of injectional anthrax to occurin the 2009/2010 outbreak, and it is an example of Bacillusanthracis causing haemorrhagic meningitis; an unusual butso far universally fatal manifestation of the disease. Thecase will be discussed within the context of the Scottishanthrax outbreak, highlighting differences in modes of pre-sentation of the newly described “injectional anthrax”.

FORTUITOUS FINDINGS

Hema Sharma 1, Ashvini Keshavan 2, Marc Lipman 3,Mark Little 2, Jennifer Cross 2, Susan Hopkins 1

1Department of Infectious Diseases, Royal Free Hospital,London, United Kingdom2University College London Centre for Nephrology,Royal Free Hospital, London, United Kingdom3Department of Respiratory Medicine, Royal Free Hospital,London, United Kingdom

Introduction

Implantable cardiac devices (CD) are used increasingly inmedical practice. As a consequence more complicationsrelated to these devices are now seen. Patients with aninfected cardiac device may present with a fever, howeverthe presence of an intravascular foreign body can makethem susceptible to atypical syndromes and thus thedifferential diagnosis in this group is wide and thesepatients must be carefully assessed to exclude a seriousunderlying pathology.

Scientific findings

A 45 year-old man with a CD presented with fevers andnight-sweats. He had pancytopenia, acute renal failure andraised inflammatory markers. A renal biopsy diagnosedpauci-immune vasculitis. He commenced immunosuppres-sion with prednisolone and cyclophosphamide. His renalfunction improved.

Subsequently,a bone marrow culture grew Mycobacte-rium fortuitum. The signi ficance was questioned, however,isolation on repeat blood cultures prompted empiricaltreatment with ciprofloxacin and clarithromycin.

He was later admitted with neutropenic sepsis, H1N1influenza and aspergillus pneumonia. Despite treatmentwith antimicrobials, antifungals and oseltamivir he de-teriorated. A key investigation revealed the actual di-agnosis. Unfortunately, he died from treatment relatedcomplications.

Discussion

A trans-thoracic echocardiogram revealed a vegetation onthe right ventricular pacing wire. The device was removedand the vegetation showed acid and alcohol fast bacilli onZiehl-Neelsen staining and mycobacteria on culture, sensi-tive to ciprofloxacin and clarithromycin.

Endocarditis complicates approximately 10% of all CDinsertions. Patients can present non-speci fically and di-agnosis is difficult. Patients with a CD and fever should beinvestigated with three sets of prolonged blood culturesand echocardiography. Rapidly growing mycobacteriararely cause endocarditis or CD infections. There are only12 reported cases in the literature, of which 8 were due toMycobacterium fortuitum.

Abstracts 499

Conclusions

Clinicians should beware of the perils of immunosuppressionin the face of a possible diagnosis of occult sepsis. Theassociation between vasculitis, glomerulonephritis and en-docarditis is well known and this case emphasizes that allcases of vasculitis should be carefully assessed for endocar-ditis. Clinicians should maintain a high index of suspicion forendocarditis in patients with a cardiac device who presentwith a fever with atypical organisms on blood culture.

“LOOK BACK IN GIEMSA”

Alexandra Cochrane 1,2, OwenMartin Williams 2, Stephen Robinson 3

1 1University of Bristol, Bristol, United Kingdom2Health Protection Agency, Bristol, United Kingdom3University Hospitals Bristol NHS Foundation Trust, Bristol,United Kingdom

Introduction

Visceral leishmaniasis (VL) is a parasitic disease endemic inthe Mediterranean basin, East Africa, Asia and SouthAmerica characterized by fever, weight loss and hepatos-plenomegaly. It is caused by protozoa of the genusLeishmania which are transmitted by the bite of thesandfly, and asymptomatic infection is common. There isa clear association between Visceral leishmaniasis andimmunosupression, most notable in the HIV infected pop-ulation but also now recognized in other immunosupressedstates including organ transplant recipients. In such casesthe protozoa may have been acquired months to yearspreviously, only causing disease when the host immunesystem is compromised. It is a serious disease, uniformlyfatal if untreated, and with a mortality of 20% with optimaltherapy in the immunosupressed. Presentation is nonspe-cific and diagnosis may be delayed where it is not activelysought. Some practitioners now advocate screening oftransplant patients prior to immunosupression and annualserological screening of immunosupressed individuals inendemic areas.

We present a case of visceral leishmaniasis post bonemarrow transplant in a patient with minimal exposure toendemic areas, and discuss the current approach to di-agnosis and management. The case highlights the impor-tance of the travel history in the febrile neutropenic,illustrates the utility of looking back at previous biopsymaterial when a new diagnosis is suspected and raises theissue of screening for rare but potentially fatal latentinfectious diseases before planned immunosupression.

Scientific findings

A 58-year old man presented with neutropenic fever,diarrhoea and abnormal liver function tests six monthsafter bone marrow transplantation for follicular lymphoma.The past medical history included treated tuberculosis and

previous episodes of graft versus host disease (GvHD). Hehad brief holidays in Greece, Egypt and The Gambia prior totransplantation. Colonic biopsies demonstrated recurrenceof GvHD. Symptoms improved following treatment forGvHD, but subsequently recurred with worsening liverfunction. A liver biopsy demonstrated leishmania amasti-gotes. Re- view of previous biopsies showed leishmania incolon and pre-transplant bone marrow. He was treated withliposomal amphotericin.

Discussion

The clinical lessons are:

1) Leishmaniasis can be acquired during brief visitsto endemic countries, so any relevant travelshould alert clinicians.

2) Visceral leishmaniasis often presents with non-speci fic symptoms and signs, clinicians shouldnot wait for hepatosplenomegaly before consider-ing thedisease.

3) Visceral leishmaniasis is usually diagnosed bydemonstrating amastigotes in tissue. As the para-site may have been present for some time it isworth looking back at previous biopsies.

4) This patient had visceral leishmaniasis beforetransplant. Screening is recommended as part ofpre-trans- plant work up in some endemic coun-tries. Should it be considered in the UK for pa-tients with travel exposure?

Conclusions

In conclusion leishmanisasis should be considered andactively sought in immunocompromised patients with feverwho have travelled to regions of endemicity. Diagnosis maybe expedited by review of previous biopsy material andscreening for leishmaniasis prior to transplant should beconsidered in selected populations.

AN UNDECLARED IMPORT

Racheol Sierra 1, Angela Houston 2, Mark Appleton 1,Sebastian Lucas 3, Joanne Legg 1

1Western Sussex Hospitals NHS Trust, Worthing,United Kingdom2Brighton and Sussex University Hospitals NHS Trust,Brighton, United Kingdom3Kings College London, London, United Kingdom

Introduction

Paracoccidiomycosis is a systemic disease caused by thethermally dimorphic fungus Paracoccidioides brasiliensis.