This Week at NEJM.org | August 30, 2012
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Perspective
D.A. Asch and K.G. Volpp | August 29, 2012 | DOI: 10.1056/NEJMp1206862
J.D. Cherry | N Engl J Med 2012;367:785-787 | Published Online August 15, 2012
S.E. Gabriel and S.-L.T. Normand | N Engl J Med 2012;367:787-790 | Published Online July 25, 2012
J.Z. Ayanian and P.J. Van der Wees | N Engl J Med 2012;367:790-793 | Published Online August 15, 2012
Original Articles
R.J. Bateman and Others | N Engl J Med 2012;367:795-804 | Published Online July 11, 2012
J.M. Venstrom and Others | N Engl J Med 2012;367:805-816
The SPS3 Investigators | N Engl J Med 2012;367:817-825
S.P. Treon and Others | N Engl J Med 2012;367:826-833
L.K. McMullan and Others | N Engl J Med 2012;367:834-841
Clinical Practice
L.M. Baddour, Y.-M. Cha, and W.R. Wilson | N Engl J Med 2012;367:842-849
Images in Clinical Medicine
M. Dutra and C. Massumoto | N Engl J Med 2012;367:850-850
R. Bassani | N Engl J Med 2012;367:e13
Case Records of the Massachusetts General Hospital
T.N. Byrne, S.J. Isakoff, S.P. Rincon, and T.M. Gudewicz | N Engl J Med 2012;367:851-861
Editorials
J.M. Drazen | N Engl J Med 2012;367:863-864 | Published Online August 8, 2012
S. Gandy | N Engl J Med 2012;367:864-866
J.S. Miller and B.R. Blazar | N Engl J Med 2012;367:866-868
Correspondence
Corrections
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TEACHING TOPICS from the New England Journal of Medicine
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Teaching Topics | August 30, 2012
CIED Infections: What is the appropriate management of cardiovascular implantable electronic device (CIED) infection?
Painful Muscle Spasms and Hyperreflexia: What clinical clues should lead to consideration of paraneoplastic syndrome?
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Teaching Topic
CIED Infections
Clinical Practice
L.M. Baddour, Y.-M. Cha, and W.R. Wilson
The use of CIEDs has increased in recent years, owing largely to the expansion of their functions and of indications for their use. Despite the use of antibiotic prophylaxis at the time of device placement or revision, rates of device-related infection may have increased, according to reports from several national databases.
Clinical Pearls
 What are the risk factors for CIED infections?
Case–control and cohort studies have identified specific risk factors associated with CIED infections. These include coexisting conditions, particularly renal failure; complications at the generator incision site, including hematoma formation; and implantation of devices with multiple leads, which are characteristic of the devices currently used. Although many studies have also identified device revision or replacement as a risk factor for infection, findings from a large, prospective, multicenter investigation of complication rates with generator replacements or upgrades (REPLACE Registry) showed a low rate of major infection (0.8%).
What is the typical presentation of a CIED infection?
Although some cases of CIED infection present without obvious inflammatory changes of the skin, the diagnosis is most often (in about 70% of cases) based on findings at the generator pocket site, including local pain, swelling, redness, drainage, and skin and soft-tissue ulceration. The first sign of infection may be erosion through the skin at the site of the generator pocket, with external exposure of the generator, one or more leads, or both the generator and leads, with or without local inflammatory changes. Less often, there is persistent local pain without obvious swelling, or healing of the incision may be delayed, which can lead to erosion.
Morning Report Questions
Q. What is the appropriate diagnostic evaluation in suspected CIED infection?
A. Blood cultures are recommended in all suspected cases of CIED infection, regardless of whether the patient is febrile or has other signs or symptoms of systemic infection. Blood samples should be drawn from different sites for at least two sets of cultures. However, blood cultures may be negative despite CIED infection, particularly in patients with pocket-site infection and in those given antibiotics shortly before blood samples are obtained for culture. Transesophageal echocardiography is recommended for patients with bacteremia, especially if the bloodstream infection is due to staphylococcal species or if the source is not identified, and for patients with signs of systemic infection, regardless of blood culture results.
Q. What is the appropriate management of CIED infection?
A. In addition to complete removal of the device, antimicrobial therapy is needed. Given the predominance of staphylococcal species as pathogens and the frequency of oxacillin resistance among these isolates, intravenous vancomycin is recommended as the initial empirical therapy pending culture results and when cultures are negative. For patients with negative blood cultures, the recommended duration of antibiotic therapy is 7 to 10 days for patients with generator or lead erosion (or both) and 10 to 14 days for infection of the generator pocket. For patients with bloodstream infection, at least 14 days of therapy is recommended. If a bloodstream infection is caused by S. aureus, antimicrobial therapy should be administered for at least 14 days after extraction of the device and from the date of negative blood cultures.
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Teaching Topic
Painful Muscle Spasms and Hyperreflexia
Case Records of the Massachusetts General Hospital
T.N. Byrne and Others
Paraneoplastic syndromes, including the stiff person syndrome, are believed to be mediated by antibodies to antigens in the neoplasm that also react to antigens expressed by the nervous system, causing clinical neurologic damage (onconeural antibodies).
Clinical Pearls
What is the clinical presentation and pathophysiology of the stiff person syndrome?
The clinical presentation of the stiff person syndrome is progressive stiffness and rigidity of the axial muscles extending into the proximal limbs, with superimposed spasms, leading to impairment of voluntary movements and gait. It is exacerbated by emotions and sensory stimuli. The syndrome is due to diminished function of γ-aminobutyric acid (GABA), the major inhibitory neurotransmitter in the central nervous system. In the spinal cord, a reduced level of GABA leads to hyperexcitable motor neurons, rigidity, and spasms of both agonist and antagonist muscles.
What is the etiology of stiff person syndrome and what autoantibodies are associated with its development?
The stiff person syndrome may be idiopathic or due to a paraneoplastic syndrome. Approximately 90% of patients with the stiff person syndrome have autoantibodies directed against glutamic acid decarboxylase, the rate-limiting enzyme for GABA synthesis. These autoantibodies are usually not associated with underlying cancer (<1 10="10" 5="5" 90="90" a="a" after="after" against="against" also="also" amphiphysin="amphiphysin" an="an" and="and" anti-amphiphysin="anti-amphiphysin" antibodies="antibodies" associated="associated" autoantibody="autoantibody" autoimmune="autoimmune" breast.="breast." but="but" cancer="cancer" contrast="contrast" diabetes="diabetes" diseases.="diseases." fifty="fifty" for="for" gaba.="gaba." have="have" in="in" is="is" may="may" mellitus="mellitus" membrane="membrane" of="of" one="one" other="other" p="p" patients="patients" protein="protein" release="release" responsible="responsible" retrieving="retrieving" series="series" synaptic="synaptic" that="that" the="the" to="to" underlying="underlying" usually="usually" vesicle="vesicle" vesicles="vesicles" with="with">
Morning Report Questions
Q. What clinical clues should lead to consideration of paraneoplastic syndrome?
A. Clinical clues that should lead to consideration of a paraneoplastic syndrome include a severe neurologic syndrome that evolves subacutely over a period of a few weeks to months, and a cerebrospinal fluid profile that includes inflammatory markers; measurement of IgG and oligoclonal bands is often helpful in determining that the disorder is inflammatory.
Q. How can limbic encephalitis be differentiated from herpes encephalitis on MRI?
A. Limbic encephalitis is an inflammatory process centered in the limbic system, manifested by behavioral and cognitive dysfunction as well as seizures. It is often a paraneoplastic syndrome. Limbic encephalitis and herpes encephalitis can be indistinguishable on imaging studies. Bilateral, asymmetric involvement of the medial temporal lobes and inferior frontal lobes is seen in both conditions. Hemorrhage is not a feature of limbic encephalitis but is usually seen in herpes encephalitis and can be a late feature. Patchy enhancement of the involved brain is seen in limbic encephalitis and in herpes encephalitis early in the disease process; later, herpes encephalitis typically shows gyriform enhancement.
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quote of the week
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“Among patients with recent lacunar strokes, the addition of clopidogrel to aspirin did not significantly reduce the risk of recurrent stroke and did significantly increase the risk of bleeding and death.”
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IMAGE CHALLENGE
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