Ulster Society of Internal Medicine 91st (Spring) Meeting Friday 23rd May 2014: Craigavon Area Hospital

Ulster Society of Internal Medicine 91st (Spring) Meeting Friday 23rd May 2014 Craigavon Area Hospital PROGRAMME: 2.00 pm An unusual case of wrist pain. D McCormick, R Stewart, M Neill, C Donnelly, H McCormick, M Mchenry. Rheumatology department, MPH, Orthopaedic department, RVH, Infectious diseases department, RVH. Microbiology department, RVH. 2.15 pm The use of novel oral-anticoagulants in the prophylaxis of stroke in non-valvular atrial fibrillation. A review of prescribing practise and outcomes in the Belfast HSC Trust. M Monaghan, K Goodwin, B Proctor, C Monteith, M Jackson, G Manoharan. Cardiology Department, Belfast Health & Social Care Trust. 2.30 pm Auditing the Launch of Formal Oxygen Prescribing Practice. G Patterson, S Graham, E McRory, R Convery. Respiratory Medicine, Craigavon Area Hospital. 2.45 pm Guest Lecture: “The initial assessment of Syncope.” Dr. John Purvis, Consultant Cardiologist, Western HSC Trust. 3.15 pm Afternoon Tea. 3.40 pm Grand Rounds: Cases from Craigavon Area Hospital Facilitator: Dr Rory Convery, Consultant Respiratory Physician, Southern HSC Trust. 4.10 pm Swollen legs, a common presentation with an unusual cause. E Teague, R Ali, E Campbell, A Hameed, Acute Medical Unit, Altnagelvin Area Hospital, Western HSC Trust. 4.25 pm Learning from an uncommon cause of a common presentation – autoimmune encephalitis on the acute medical ward. G McCluskey, G Lewis, P Gardiner and M McCarron. Department of Medicine, Altnagelvin Area Hospital, Western HSC Trust. 4.40 pm Presentation of prize for the best abstract. 4.45 pm Guest Lecture: “ACS and provision of 24/7 primary PCI in Northern Ireland.” Dr Michael Moore. Consultant in Invasive Cardiology, Western HSC Trust. AN UNUSUAL CASE OF WRIST PAIN D McCormick, R Stewart, M Neill, C Donnelly 3 H McCormick, M Mchenry. 1. Rheumatology department, Musgrave park hospital. 2. Orthopaedic department, Royal Victoria hospital. 3. Infectious diseases department, Royal Victoria hospital. 4. Microbiology department, Royal Victoria hospital 66 year old gentleman with a significant past medical history including autoimmune hepatitis requiring Immunosuppression with azathioprine and low dose prednisolone, previous deep venous thrombosis and atrial fibrillation requiring warfarinisation, pulmonary fibrosis, gout and osteoarthritis. Presented to rheumatology service with monoarthropathy of right wrist in April 2013. Joint injection provided minimal benefit. Symptoms progressed over the following six months with increased pain and diffuse swelling of distal forearm and hand. Wrist aspirate in August suggested calcium pyrophosphate crystals but also cultured candida albicans on enrichment which was felt to be a contaminant. Further wrist aspirate in October, however, again cultured candida albicans. MRI of wrist showed gross tenosynovitis of extensor and flexor tendons as well as synovitis and effusion in wrist. A low grade inflammatory process was suspected likely secondary to candida. Aspirate from olecranon bursa swelling also cultured Candida albicans. There was no evidence of systemic candidiasis and the source of infection is unclear but case reports suggest rose thorns as a potential route of entry. Despite 2 weeks of intravenous anti-fungal therapy, repeat joint aspirates continued to culture candida. Repeat MRI scan showed further progression and suggested osteomyelitis of carpal bones. MRI elbow showed a large distended olecranon bursa as well as likely osteomyelitis of the olecranon. Failure of conservative management of this rare and complex condition prompted transfer to orthopaedics where he has subsequently undergone endoscopic olecranon bursectomy and at a later date tenosynovectomy and ultimately may require amputation. We await the outcome of this unfortunate gentleman.