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• W2132555462 abstract "A previously fit, 78-year-old retired farmer established on haemodialysis for 5 years, presented with anorexia and severely altered mental state, singing ecclesiastical hymns all day long. Clinical examination revealed only the presence of an already known pansystolic murmur at the mitral area. He was not on any medication that could be implicated in causing acute confusion, he had never been treated with aluminium-containing phosphate binders in the past and his wife confirmed that he had not ingested star fruit or unusual mushrooms recently. His white cell count was 12 000 (89% neutrophils), Hb 9.8 g/dl with normal mean corpsular volume (MCV), erythrocyte sedimentation rate (ESR) 98 and C-reactive protein(CRP) 15mg/dl. Full biochemistry, arterial blood gases, three sets of blood cultures, urine culture, chest x-ray, thyroid function tests, Treponema Pallidum Haemaglutination Assay and CT head were all normal. His disturbed psychological and mental state was gradually deteriorating with intense ideas of persecution. He was refusing food and was continuously murmuring incomprehensible religious hymns. There was no pyrexia [Pyrexia1⁄4Fever (origin greek ‘pyr’ meaning fire, pyrexial1⁄4 somebody ‘who is on fire’)] or other new clinical signs but he had persistently raised ESR and CRP, suggesting an organic cause for his symptoms. A repeat full septic screen (including a lumbar puncture with India Ink staining for cryptococci), clotting, Vit B12 levels, virology and vasculitis screen, Brucella and Chlamydia titres and bone marrow aspiration for tuberculosis were all negative. There was, however, a strongly positive rheumatoid factor (RF). Within the next few days the patient’s clinical condition deteriorated significantly to the extent that he was unable to communicate with his environment. Examination was again unremarkable with no focal neurology and no pyrexia. Because of the combination of positive RF and CRP, repeat blood cultures were taken with the request to be incubated for 7 days for the HACEK group of bacteria (Haemophilous, Actinobacillus, Cardiobacterium, Eikenella and Kingella), known to be involved in infective endocarditis. A transoesophageal echocardiogram was requested but, due to a long waiting list, a trans-thoracic Echocardiogram was first performed by the cardiology team which was reported as showing mild/moderate mitral regurgitation but no vegetations. The patient’s condition deteriorated even more to the extent that we were contemplating the cancellation of his transoesophageal echocardiogram when he was called for it, as he was so ill. The latter, however, revealed the presence of severe mitral regurgitation with a posterior leaflet vegetation. He was started on benzyl penicillin, gentamicin and vancomycin. Within 48 h his general condition improved. Seven days into treatment he was back to normal, eating and drinking. His blood cultures remained negative. He continued antibiotics for a total of 6 weeks and now continues on haemodialysis thrice weekly and occasionally sings the odd ecclesiastical hymn as a reminder to us all of his near-fatal episode. Correspondence and offprint requests to: Polycarpos Polycarpou. Email: drpolys@cytanet.com.cy Nephrol Dial Transplant (2007) 22: 945–948" @default.
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• W2132555462 date "2007-01-05" @default.
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• W2132555462 title "From the heart to the soul" @default.
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• W2132555462 doi "https://doi.org/10.1093/ndt/gfl726" @default.
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