Clinical medicine (London, England)
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The use of regular infusions of immunoglobulin is well established as a treatment for patients with antibody deficiency and for patients requiring immunomodulation. Although efficacy is believed to be equivalent for the different immunoglobulin products, it is generally regarded as best practice not to switch from one product to another unless there is a clinical reason to change. Changes in commissioning guidance and issues with the supply of some immunoglobulin products to the UK resulted in a requirement for a significant number of patients to switch between immunoglobulin products in 2017-2018. ⋯ Results from 30 immunology centres reported a total of 802 immunoglobulin product switches. Twelve reactions were recorded, none of which required admission to hospital, one patient was treated with oral corticosteroids, the others required either no treatment or treatment with oral antihistamines. This review of immunoglobulin product switch reactions gives a clearer indication regarding the safety of product switching than has previously been published.
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Pulmonary embolism, despite being common, often remains elusive as a diagnosis, and clinical suspicion needs to remain high when seeing a patient with cardiopulmonary symptoms. Once suspected, diagnosis is usually straightforward; however, optimal treatment can be difficult. ⋯ Direct oral anticoagulants have been a major advance in treatment this decade, but are not appropriate for all patients. Follow-up of patients with pulmonary embolism should be mandatory to determine duration of anticoagulation and to assess for serious long-term complications.
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Case Reports
Lesson of the month 1: Neurosyphilis mimicking viral encephalitis and ischaemic stroke.
With the incidence of syphilis more than doubling over the last decade, knowledge of its manifestations is of increasing importance. Yet, today's clinicians are less experienced in the recognition of syphilis than the physicians of Osler's day. In this case, a 56-year-old man presented with acute confusion and a history suggestive of encephalitis. ⋯ This variability adds to the challenge of diagnosis. Thus syphilis serology screening should be sent in those presenting with acute confusion and neuroimaging abnormalities. In cases of cryptogenic stroke, syphilis serology should be added to the screening tests.
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Case Reports
Lesson of the month 2: Fever, arthralgias and hyperkeratotic, scaling and fissuring eruptions of the hands.
A 56-year-old male hairdresser, presented with fever and arthralgias. He had a worsening 'eczematous' palmar rash which had been attributed to irritation from colouring products used in his work. On examination, hyperkeratotic, fissuring eruptions were noted on the palmar side of his fingers and lung auscultation revealed crackles on both lower lobes. ⋯ This is a characteristic semiology reminiscent of hands of manual workers, resembling hand eczema. 'Mechanic's hands', fever, arthralgias, lung findings and elevated serum muscle enzymes raised the possibility of antisynthetase syndrome. Testing for myositis autoantibodies revealed anti-Jo-1 and anti-Ro52 reactivity supporting the diagnosis. Greater awareness of the typical clinical feature of 'mechanic's hands' will allow for earlier diagnosis and appropriate treatment in patients with antisynthetase syndrome.
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Bronchiectasis is a chronic inflammatory condition with a diverse aetiology including recurrent infections, genetic abnormalities, immunodeficiency and autoimmune disorders. The prevalence has increased over the past few years and this may be due to better imaging and diagnostic techniques. Management remains the emphasis for improving symptoms and reducing exacerbations. This article focuses on highlighting the latest data released since 2014 on new diagnostic techniques as well as potential future pharmacological and non-pharmacological treatment options for patients with bronchiectasis.