Objective: To analyse cases of blood culture negative endocarditis (BCNE) seen at St Thomas ' Hospital, London, between 1975 and 2000.Methods: Data on all episodes of endocarditis with negative blood cultures seen at St Thomas' Hospital between 1975 and 2000 were collected prospectively and analysed retrospectively.Results: Sixty three patients with BCNE were seen during the study period: 48 (76%) with native and 15 (24%) prosthetic valve infection.BCNE accounted for 12.2% of the 516 cases of endocarditis seen at St Thomas' Hospital.The diagnosis of endocarditis was clinically definite by the Duke criteria in only 21% (7 of 34) of cases of pathologically proven native valve endocarditis but in 62% (21 of 34) of cases by the St Thomas' modifications of the criteria.Comparable figures for the 11 cases of pathologically proven prosthetic valve endocarditis were 45% and 73%.Despite negative blood cultures a causative organism was identified in 31 (49%) of the 63 cases: in 15 by serology (8 Coxiella burnetii, 6 Bartonella species, and 1 Chlamydia psittaci); in 9 cases by culture of the excised valve; in 3 by microscopy of the excised valve, on which large numbers of Gram positive cocci were seen although the culture was sterile; and in the other 4 by isolation from a site other than the excised valve (2 respiratory specimens, 1 from the pacemaker tip, and 1 from an excised embolus).In addition 5 of the 6 cases of Bartonella infection were confirmed by polymerase chain reaction study of the excised valve.Two thirds of the 32 patients for whom no pathogen was identified had received antibiotics before blood was cultured.Thus truly "negative" endocarditis was very uncommon (6% of the cases).Conclusion: If blood cultures are negative in definite or suspected endocarditis, serum should be analysed for Bartonella, Coxiella, and Chlamydia species antibodies, and the excised valve or (rarely) embolus should be analysed by microscopy, culture, histology, and relevant polymerase chain reaction.Other specimens may be relevant.The Duke criteria performed poorly in BCNE; St Thomas' additional minor criteria gave more definite diagnoses.. . . . . .

EDITOR—We support Causer and Connolly's editorial emphasising the value of implantable cardioverter-defibrillators in patients with life threatening ventricular arrhythmias.1 A recent audit conducted in our cardiac unit highlights two additional issues: psychosocial concerns of patients and cost implications. We reviewed clinical records and psychosocial structured questionnaires of the 42 patients receiving their first implantable cardioverter-defibrillator (through pectoral routes) between January 1995 and February 1998 (table). To our knowledge, this is the first reported series of such patients in the …

Write: We report two cases of rhabdomyolysis and multiple system organ failure with streptokinase treatment. A 47 year old normotensive (110/70 mm Hg) man with normal renal function suffered an inferoposterior myocardial infarction treated with oral aspirin (300 mg). Lumbar pain accompanied intravenous streptokinase (1.5x106 units over one hour). At three hours renal, respiratory, and high output circulatory failure with fever ensued despite inotropes and fluids. At 17 hours his temperature was 39.2°C, blood pressure 70/40 mm Hg, urea 22 mmol/l, creatinine 400 μmol/l; urine red+ and white cells+ …

In a recent survey of 100 consecutive patients with rheumatoid arthritis (RA) attending a rheumatology outpatient department, over 7500 had received a course of oral iron during their disease and 40%h multiple (up to 12) courses (D R Blake and D G I Scott, unpublished observations). Since these figures almost certainly do not indicate the true incidence of iron deficiency, we have assessed the value of standard haematological indices of iron state to predict low iron stores. Serum ferritin concentration is a particularly sensitive index of low iron stores in RA,1 and has, therefore, been accepted as the absolute iron state in our study. Patients with a low serum ferritin concentration were further investigated to assess the cause of their iron deficiency.