Muscle dysfunction related to clozapine treatment is largely unrecognized. We evaluated weekly creatine kinase (CK) levels in 37 consecutive clozapine-treated outpatients with chronic psychotic disorders. Those with CK elevations underwent clinical neurologic evaluation, electromyography (EMG), and nerve conduction studies. Patients with probable myopathy had a quadriceps muscle biopsy. Twenty control patients had a single CK level determination. Twenty-nine of 37 clozapine-treated patients had CK elevations. Three patients had extreme CK elevations (> 20,000 IU/L), without myoglobinuria. Mean CK levels were significantly greater in clozapine patients (194 IU/L) than in control patients (142.3, p = 0.033). Of 18 clozapine-treated patients evaluated clinically, 6 had mild proximal weakness. EMG in 13 patients was myopathic in 5, normal in 5, and neurogenic in 3. Muscle biopsy in 5 patients showed rare regenerating myofibers and mild acute denervation (1), mild type II fiber atrophy (1), minimal acute denervation (1), and normal muscle (2). In conclusion, clozapine therapy may be associated with CK elevations and, rarely, mild myopathy.

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Infectious endocarditis of the tricuspid valve (TV) is a common complication of intravenous (IV) drug use. Endocarditis caused by viridans streptococci can lead to heart valve vegetations, which may be life-threatening due to the potential for embolism and obstruction. The management of large valvular vegetations is often difficult due to the risks involved with open heart surgery, especially in patients with comorbid conditions. The AngioVac device (AngioDynamics Inc., Latham, NY) has been shown in rare cases to be effective at debulking vegetations without the need for invasive surgery. We present a 45-year-old male with a history of intravenous heroin use disorder, hepatitis C, spinal abscesses, and chronic anemia who experienced worsening shortness of breath, generalized weakness, bilateral lower extremity edema, dysuria with dark urine, and blood on toilet paper. Workup revealed a 4.39 × 4.35 cm tricuspid valve vegetation, severe tricuspid regurgitation (TR), acute renal failure, acute on chronic anemia, and thrombocytopenia from sepsis-induced disseminated intravascular coagulation (DIC). AngioVac was used to aspirate the vegetation and effectively reduced the size to 3.75 × 2.31 cm. Follow-up blood cultures revealed no growth after five days. This is the largest documented tricuspid valve vegetation with a successful implementation of the AngioVac to date. This therapy, in conjunction with intravenous antibiotics and hemodialysis, successfully sterilized the vegetation, prevented worsening presentation, and averted life-threatening complications, although severe tricuspid regurgitation persisted. Based on the findings of this case, the AngioVac device is a safe and effective treatment option for tricuspid valve endocarditis patients with large vegetation and severe comorbidities, which contraindicate open heart surgery.

In 1937 Vollmer and Goldberger 1 described a new tuberculin patch test and compared its results with those of the Pirquet test in 209 tuberculous children. Their study showed conformity of results in 187 patients, or 89.5 per cent, and nonconformity in 22, or 10.5 per cent, with 15 of the latter reacting positively to the patch test and negatively to the Pirquet test. From the point of view of reliability, this new test was considered superior and had the added advantage of simplicity.In the following year these authors 2 published observations on 169 tuberculous children, employing for the patch test tuberculin3 approximately four times stronger than that originally used, and compared the results with those of the Mantoux intracutaneous test, using purified protein derivative. Only 1 child failed to react to the patch test who at the same time reacted positively to the intracutaneous test. In a subsequent study4 of 417 unselected children they reported the reliability of the patch test as compared with the Mantoux test, using 0.1 mg. of old tuberculin, to be practically 100 per cent ; only 4 results showed lack of conformity, and 3 of these were positive reactions to the patch test.