Worsening encephalopathy (as well as myoclonus and seizures) in a patient with renal insufficiency can be due to the antibiotic, cefepime.
A woman in her thirties has a cough for three weeks, and dysphagia for one day. Chest x-ray shows a right paratracheal mediastinal mass. On mediastinoscopy a mass adheres to the right medistinum. It has septated pus. Pathology shows only necrotizing granulation. No malignancy. All cultures are negative for bacteria and fungus.
This case most probably is mediastinal granuloma due to histoplasmosis. Serologic evidence is pending.
Scott Williams, MD provides some online examples of mediastinal granuloma [1], medistinal fibrosis [2], and a case of histoplasmosis masquerading as sarcoidosis [3].
Does medistinal granuloma forebode mediastinal fibrosis and indicate corticosteroids? Most apparently think not. (I am awaiting the papers cited by Dr. Williams and found on Pubmed, including a CPC from the New England Journal, April 11, 1991.)
(The American Academy of Family Practice has a good general review of histoplasmosis online. [4])
--- --- ---
Here are other references grabbed from Pubmed and not yet received:
References on Mediastinal Granuloma
Bernard AC, Mullett TW. Mediastinal granuloma complicating histoplasmosis.
J Ky Med Assoc. 2003 Jan;101(1):12-4.
Gula LJ, Malthaner RA, Quantz MA. Pyopneumopericardium caused by mediastinal granuloma.
Ann Thorac Surg. 2002 Jul;74(1):241-3.
Mocherla S, Wheat LJ. Treatment of histoplasmosis.
Semin Respir Infect. 2001 Jun;16(2):141-8. Review.
Savides TJ, Gress FG, Wheat LJ, Ikenberry S, Hawes RH. Dysphagia due to mediastinal granulomas: diagnosis with endoscopic ultrasonography. Gastroenterology. 1995 Aug;109(2):366-73.
Marshall JB, Singh R, Demmy TL, Bickel JT, Everett ED. Mediastinal histoplasmosis presenting with esophageal involvement and dysphagia: case study. Dysphagia. 1995 Winter;10(1):53-8.
Maholtz MS, Dauber JH, Yousem SA. Case report: fluconazole therapy in histoplasma mediastinal granuloma.
Am J Med Sci. 1994 Apr;307(4):274-7.
Lerner MH, DeLuca SA. Mediastinal granuloma secondary to histoplasmosis.
Am Fam Physician. 1991 May;43(5):1649-51.
[No authors listed] Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 15-1991. A 48-year-old man with dysphagia, chest pain, fever, and a subcarinal mass.
N Engl J Med. 1991 Apr 11;324(15):1049-56. No abstract available.
Dunn EJ, Ulicny KS Jr, Wright CB, Gottesman L. Surgical implications of sclerosing mediastinitis. A report of six cases and review of the literature.Chest. 1990 Feb;97(2):338-46. Review.
Landay MJ, Rollins NK. Mediastinal histoplasmosis granuloma: evaluation with CT. Radiology. 1989 Sep;172(3):657-9
Loyd JE, Tillman BF, Atkinson JB, Des Prez RM. Mediastinal fibrosis complicating histoplasmosis. Medicine (Baltimore). 1988 Sep;67(5):295-310. Review.
Strimlan CV, Dines DE, Payne WS. Mediastinal granuloma.
Mayo Clin Proc. 1975 Dec;50(12):702-5.
Rossi SE, et al. From the archives of the AFIP: Fibrosing mediastinitis. Radiographics 2001; 21: 737-757
Sherrick AD, et al. The radiographic findings of fibrosing mediastinitis. Chest 1994; 106: 484-489
Swelling, tenderness, redness of the external ear (pinna). How can cellulitis of the pinna be distinguished from relapsing polychondritis?
Our case of pinna cellulitis had submandibular swelling and tenderness suggesting infection. Also, symptoms had not been relapsing.
A University of California San Francisco (UCSF) HIV website comments on pinna cellulitis. "The pathophysisiology, the organisms involved, and the incidence of these infections in the HIV-Infected patient appear to be the same as in the immunocompetent patient. Staphylococcus aureus is the most common organism isolated for the pinna cellulitis, whereas pseudomonas aeruginosa is frequently isolated from patients with otitis externa."