Clinical medicine (London, England)
-
Case Reports
Continuous glucose monitoring for diabetes: potential pitfalls for the general physician.
A 31-year-old man presented systemically unwell with diabetic ketoacidosis (DKA). He was using an intermittently scanned continuous glucose monitoring (CGM) device that had been recording low or normal glucose readings for the 48 hours prior to admission. The sensor site had become infected, and we believe this soft tissue infection caused his CGM device to record falsely low glucose readings leading the patient to erroneously lower his insulin doses and take extra carbohydrates, precipitating DKA. ⋯ When interstitial glucose readings do not match symptoms or expectations, a capillary blood glucose reading should be taken to correlate and impact treatment decisions. There will be an increase in patients presenting to hospital with CGM devices as the National Institute for Health and Care Excellence guidelines have recently been updated. We use this interesting clinical case to provide context for key learning points about CGM devices for the general physician.
-
Although seemingly benign, the presence of a patent foramen ovale (PFO) may play an important role in the pathophysiology of disease, specifically a paradoxical embolism leading to cryptogenic stroke. The European Society of Cardiology recently published guidelines detailing how PFOs are associated with paradoxical embolism and how they are diagnosed and managed. ⋯ It reviews the clinical trials comparing device closure with medical therapy and highlights the current NHS England commissioning process on PFO management. Finally, we give an overview of other conditions where PFO device closure may need to be considered.
-
Case Reports
Lesson of the month: Cytotoxic lesions of the corpus callosum (CLOCCs) in status epilepticus.
A 26-year-old man was diagnosed with epilepsy a few months previously and admitted with status epilepticus. Computed tomography (CT) of the brain and CT venography were unremarkable. Magnetic resonance imaging (MRI) of the brain showed evidence of possible acute focal infarction in the splenium of the corpus callosum that showed a true restricted diffusion. ⋯ MRI of the brain was repeated 1 month later to assess for progression of that lesion and showed resolution of it. This case highlights the association of cytotoxic lesions of the corpus callosum that show true restricted diffusion with status epilepticus. It also emphasises the importance of medical reasoning and not being solely dependent on diagnostic investigations without reasonably linking them to the history and examination.
-
Sepsis-associated encephalopathy (SAE) describes acute cognitive dysfunction secondary to systemic or peripheral infection occurring outside of the central nervous system (CNS). Symptoms can range from mild confusion to coma and may precede the clinical signs of sepsis. Recognition that SAE is a potential differential diagnosis in patients presenting with delirium is important, as SAE is a diagnosis of exclusion. ⋯ Although mortality is often secondary to multiorgan failure rather than neurological sequelae, long-term cognitive and psychological morbidities have been reported in sepsis survivors. Early treatment (which can include prompt identification and source control of the infection) and good supportive care might improve cognitive outcomes. Future work should aim to improve understanding of both acute and chronic SAE with a focus on therapeutic interventions and improving patient outcomes.