There is no doubt that this Winter has been tough for those of us working in Acute Medical Units. At the time of writing I find myself in the depths of the post-Christmas blues; the combination of Bank Holidays, ward closures, junior doctor illness and huge admission surges have conspired to make January even more challenging than normal. No doubt the printing delays will have meant that, by the time you are reading this Editorial, these days will be a distant memory. Maybe this will serve as a useful reminder of the need for forward planning in time for next year, rather than breathing the usual sigh of relief as we steel ourselves for Easter. Perhaps a more imaginative colour coding system for our ‘alert’ system would be a start – simply alternating between ‘red alert’ (awful) and ‘black alert’ (even worse) can become quite tedious as the weeks pass. A few shades of maroon or magenta to remind us that ‘today is slightly better than yesterday’ might help break the monotony. We could even opt for a full rainbow spectrum to signify the hope that one day all of our efforts will be worthwhile….it’s important to stay positive in these difficult times! I frequently tell our students ‘When you hear hooves, think horses…not zebras’ – an alternative (and unoriginal) way to remind them that ‘common things occur commonly’. But of course not all chest pain is ischaemic in origin, and not every fever is caused by pneumonia – even in January. The case reports in this edition illustrate some of the more unusual causes of acute medical admission, and the importance of maintaining an open mind. Takotsubo cardiomyopathy is a condition which seems to have passed me by in my medical practice to-date; on reading this case I wondered how many patients I have inappropriately thrombolysed over the past 15 years. In the new world of Heart Attack Centres and urgent percutaneous intervention maybe we will find it is more common than was previously thought. Porphyrias and vasculitidies are occasionally sent to challenge us, but give us the opportunity to demonstrate the power of lateral thinking which distinguishes us as Physicians. As the authors remind us in their title – porphyria will only be diagnosed if it is considered in the differential; it is easy forget that the combination of psychiatric illness and abdominal pain does not always imply Irritable Bowel Syndrome! Cerebral Nocardiosis should not feature high up in the differential diagnosis when a 90 year old patient presents with a hemiparesis, even in the context of immune deficiency. The temptation to presume that the ‘ring enhancing lesion’ seen on his CT was neoplastic, must have been considerable for the team caring for this patient. The importance of a tissue diagnosis, even in this age group, is emphasised by the outcome of this case. I hope you enjoy this edition and hopefully we are now getting back on track with the scheduling. Please keep the submissions coming in; we are starting to receive some interesting pieces of research, which will be included over the next year pending review. If any more readers would like to volunteer to become editorial referees for future editions, please feel free to contact me directly on the email shown.
Cerebral Nocardiosis in a patient with Waldenstrom’s Macroglobulinaemia
