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Background Jolt accentuation has been considered to be the most sensitive physical finding to predict meningitis. However, there are only a few studies assessing the diagnostic accuracy of jolt accentuation. Therefore, we aimed to evaluate the diagnostic accuracy of jolt accentuation and investigate whether it can be extended to patients with mild altered mental status. Methods We performed a single center, retrospective observational study on patients who presented to the emergency department in a Japanese tertiary care center from January 1, 2010 to March 31, 2016. Jolt accentuation evaluated in patients with fever, headache, and mild altered mental status with Glasgow Coma Scale no lower than E2 or M4 was defined as 'jolt accentuation in the broad sense.' Jolt accentuation evaluated in patients with fever, headache, and no altered mental status was defined as 'jolt accentuation in the narrow sense.' We evaluated the sensitivity and specificity in both groups. Results Among 118 patients, the sensitivity and specificity of jolt accentuation in the broad sense were 70.7% (95% confidence interval (CI): 58.0%-80.8%) and 36.7% (95% CI: 25.6%-49.3%). The positive likelihood ratio and negative likelihood ratio were 1.12 (95% CI: 0.87-1.44) and 0.80 (95% CI: 0.48-1.34), respectively. Among 108 patients, the sensitivity and specificity of jot accentuation in the narrow sense were 75.0% (95% CI: 61.8%-84.8%) and 35.1% (95% CI: 24.0%-48.0%). The positive likelihood ratio and negative likelihood ratio were 1.16 (95% CI: 0.90-1.48) and 0.71 (95% CI: 0.40-1.28), respectively. Conclusions Jolt accentuation itself has a limited value in the diagnosis of meningitis regardless of altered mental status. Therefore, meningitis should not be ruled out by negative jolt accentuation. [ABSTRACT FROM AUTHOR]

Background: Various complications are reported with Clostridium difficile infection (CDI), including fulminant CDI. Fulminant CDI is an underappreciated life-threatening condition associated with complications such as toxic megacolon and bowel perforation.Case Report: A 79-year-old woman presented to the Emergency Department with altered mental status. She was admitted and conservatively treated for a left thalamic hemorrhage. While hospitalized, she developed watery diarrhea due to Clostridium difficile. Although metronidazole was initiated, she developed altered mental status and septic shock. Abdominal x-ray study and computed tomography revealed a significantly dilatated colon and a massive pneumoperitoneum. She underwent subtotal colectomy with a 14-day course of intravenous meropenem. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case suggests that we must be aware of the complications that CDI may present and adequately consider surgical management because early diagnosis and surgical treatment is critical to reduce the mortality of fulminant CDI. [ABSTRACT FROM AUTHOR]

Rat-bite fever (RBF) is a challenging diagnosis transmitted by the bite of the rats. We present the first reported case of RBF complicated by vertebral osteomyelitis. It is important to consider performing the MRI to differentiate vertebral osteomyelitis from simple back pain to determine the appropriate duration of antibiotic therapy. [ABSTRACT FROM AUTHOR]

Background: While nontuberculous mycobacterial (NTM) pleuritis rarely complicates pulmonary NTM infection, high mortality has been reported in case reports and small studies. Objectives: The purpose of this study was to clarify the clinical features and treatment outcomes of pulmonary NTM infection cases accompanied by NTM pleuritis. Methods: Medical records of 1,044 patients with pulmonary NTM disease were retrospectively reviewed to select patients complicated by NTM-proven pleuritis. We investigated clinical characteristics, pathogens, pleural effusion examinations, radiographic findings, treatments, and clinical course of the NTM pleuritis patients. Results: Among 1,044 cases with pulmonary NTM, NTM pleuritis occurred in 15 cases (1.4%). The mean age was 69 years with a performance status of mostly 2 or better (80.0%), and 6 cases (40.0%) were complicated by pneumothorax. Subpleural cavities were radiologically detected in 11 cases (73.3%), and extrapulmonary air-fluid level was detected in 14 cases (93.3%). Eleven patients were treated with combinations of 2–4 antimycobacterial drugs, including clarithromycin, and 2 patients were treated with isoniazid, rifampicin, and ethambutol. Chest tube drainage was performed in 11 cases, and surgical approach was added in 6 cases. The pleural effusion of 2 patients treated with only antimycobacterial medications gradually deteriorated. Two patients died from NTM pleuritis, and 1 patient died from pneumonitis during a mean of 1.8 years of follow-up. Conclusions: Comorbid NTM pleuritis was difficult to treat by medical therapy alone and resulted in a poor prognosis. In addition to antimycobacterial agents, chest tube drainage and surgical procedures in the early stages should be considered to treat NTM pleuritis. [ABSTRACT FROM AUTHOR]