Tuberculosis of the meninges and central nervous system. Experience of clinical diagnostics in St. Petersburg for 50 years

The clinic and diagnostics of tuberculosis meningitis (TM) in 926 patients treated in St. Petersburg hospitals in 1965–1994 (group 1) and in 1995–2018 (group 2) is presented. The TM clinic is demonstrated to be determined by the form of tuberculosis and its characteristic generalization nature in the presence of repeated waves of bacteremia and allergic vasculitis of greater or lesser severity. There is clinical peculiarity of TM in primary pulmonary tuberculosis and its early large-focal and late miliar generalization, as well as in hematogenous tuberculosis. In patients of the 1st and 2nd groups the TM clinic shows in some respects a noticeable similarity, in others — a significant difference. Despite the typical symptoms, early diagnosis of TM took place in less than 20% of patients. Clinical examples illustrating the unusual development of TM, contrasting with its usual course, are given. A number of objective and subjective factors contributing to the adverse evolution of TM and its lethal outcome are discussed. These include the peculiarity of modern tuberculosis, especially when associated with HIV infection, as well as medical errors associated with ignorance of the pathogenesis of tuberculosis and failure to comply with the minimum examination for tuberculosis.

The idiopathic form of Sweet's syndrome

A clinical case of Sweet’s syndrome (dermatosis neutrophilica febrilis acuta) in a 59-year old man is presented. The data about etiology, pathogenesis and clinical picture are summarized. Difficulties in diagnosis of the disease are described. Sweet’s syndrome is characterized by skin lesions with marked neutrophilic infiltration. The syndrome manifests itself as a rash ofpainful red papules, plaxes, intradermal nodes on the head, neck and hands, multiple ostiofolliculitis. It is also characterized by fever, leukocytosis, arthralgias, episcleritis. Approximately 15% of cases are paraneoplastic. Patergiya can be seen in patients. It is a skin condition, characterized by lesions due to minor injuries. Diagnosis is based on a combination of clinical, physical, laboratory examinations and histological changes. The differential diagnosis should be made with exudative erythema multiforme, allergic vasculitis, erythema elevatum diutinum and erythema nodosum.

Clozapine-Induced Late Agranulocytosis and Severe Neutropenia Complicated withStreptococcus pneumonia, Venous Thromboembolism, and Allergic Vasculitis in Treatment-Resistant Female Psychosis

Clozapine is a second-generation antipsychotic agent from the benzodiazepine group indicated for treatment-resistant schizophrenia and other psychotic conditions. Using clozapine earlier on once a case appears to be refractory limits both social and personal morbidity of chronic psychosis. However treatment with second-generation antipsychotics is often complicated by adverse effects. We present a case of a 33-year-old Caucasian woman with a 25-year history of refractory psychotic mania after switching to a 2-year clozapine therapy. She presented clozapine-induced absolute neutropenia, agranulocytosis, which were complicated byStreptococcus pneumoniaand sepsis. Clozapine-induced thromboembolism of the common femoral and right proximal iliac vein, as well as allergic vasculitis, was diagnosed. She achieved full remission on granulocyte-colony stimulating factor and specific antibiotic treatment. Early detection of severe clozapine-induced absolute neutropenia and agranulocytosis enabled the effective treatment of two among its most severe complications. Additional evidence to the previously reported possible causal relation between clozapine and venous thromboembolism is offered. Finally, clozapine-induced allergic vasculitis is confirmed as a late adverse effect of clozapine therapy.