History and admission diagnosis: A 65-year-old man, known to have had a gastric ulcer and chronic rheumatoid arthritis as well as alcohol and nicotine abuse, was admitted because of suspected endocarditis. Physical examination revealed marked pain on pressure over the throacic spine. Vesicular breath sounds were reduced over the entire thorax and there was a systolic murmur over Erb's point (above the right clavicle). There was a purulent bursitis over the olecranon.Investigations: Abnormal laboratory tests were: elevated C-reactive protein, elevated leucocyte count (up to 33 thousand during the hospital stay). Smears from the bursitis and blood cultures revealed Staph. aureus. Computed tomography demonstrated a fracture of the 7th thoracic vertebra with a paravertebral abscess. Echocardiography showed anatherosclerotic aortic valve with floating particles.Diagnosis, treatment and course: Treatment of the suspected staphylococcal bacteraemia with purulent bursitis, spondylitis and aortic valvar endocarditis was begun with broad-spectrum antibiotics, but the patient soon developed a severe acute respiratory distress syndrome and he died of multi-organ failure. Autopsy revealed as cause of death left heart failure with aortic valvar endocarditis and gelatinour pneumonia caused by late tubercular dissemination from the tubercular spondylitis.Conclusion: Tuberculosis can be a life-threatening infection. Uncharacteristic history and extrapulmonary manifestations can make it very difficult to arrive at the correct diagnosis.

HISTORY AND ADMISSION DIAGNOSIS:A 65-year-old man, known to have had a gastric ulcer and chronic rheumatoid arthritis as well as alcohol and nicotine abuse, was admitted because of suspected endocarditis. Physical examination revealed marked pain on pressure over the throacic spine. Vesicular breath sounds were reduced over the entire thorax and there was a systolic murmur over Erb's point (above the right clavicle). There was a purulent bursitis over the olecranon.INVESTIGATIONS:Abnormal laboratory tests were: elevated C-reactive protein, elevated leucocyte count (up to 33 thousand during the hospital stay). Smears from the bursitis and blood cultures revealed Staph. aureus. Computed tomography demonstrated a fracture of the 7th thoracic vertebra with a paravertebral abscess. Echocardiography showed anatherosclerotic aortic valve with floating particles.DIAGNOSIS, TREATMENT AND COURSE:Treatment of the suspected staphylococcal bacteraemia with purulent bursitis, spondylitis and aortic valvar endocarditis was begun with broad-spectrum antibiotics, but the patient soon developed a severe acute respiratory distress syndrome and he died of multi-organ failure. Autopsy revealed as cause of death left heart failure with aortic valvar endocarditis and gelatinour pneumonia caused by late tubercular dissemination from the tubercular spondylitis.CONCLUSION:Tuberculosis can be a life-threatening infection. Uncharacteristic history and extrapulmonary manifestations can make it very difficult to arrive at the correct diagnosis.

The hemodynamic and myocardial energetic changes due to pulsus alternans were investigated by left and right heart catheterization and by oxygen consumption measurements in three patients with dilative cardiomyopathy. In all three patients, pulsus alternans developed after intravenous administration of the phosphodiesterase inhibitor enoximone. Following enoximone (Patients 1/2/3), left ventricular peak systolic pressure was reduced, in the respective patients, from 100/103/115 mmHg (normal beat) to 91/96/94 mmHg (strong beat) and further to 59/80/85 mmHg (weak beat); left ventricular end-diastolic pressure was reduced from 24/23/22 mmHg (normal beat) to 5/10/6 mmHg (strong beat) and further to 3/7/4 mmHg (weak beat). Cardiac output increased by an average of 16%. Heart rate increased by an average of 12%. Stroke work (during pulsus alternans mean between strong and weak beats) did not change (less than 5%) in any of the three patients. Arterial-coronary-sinus oxygen content difference decreased by 5%/13%/22, respectively. Myocardial oxygen consumption per beat decreased in Patient 1 by 8%, in Patient 2 by 8% and remained unchanged in Patient 3. It is concluded that pulsus alternans occurred in consequence of alternating systolic performance. The alternation in systolic performance most probably resulted from a disturbance in excitation-contraction coupling induced by enoximone. The pronounced reduction of left ventricular preload following administration of enoximone may have augmented further the differences between the strong and the weak beat. A disturbance in myocardial oxygen metabolism was ruled out as the cause of pulsus alternans in these patients.