Adult-onset Still disease (AOSD) is an uncommon clinical entity that predominantly affects young adults. One of the most common presentations of the disease is fever of unknown origin. Early diagnosis can be difficult because fever of unknown origin is more commonly seen with other conditions such as malignancy or infection. Ambiguity in presentation and lack of serologic markers make diagnosis difficult.We describe here an 18-year-old African-American man who presented with fever, sore throat, and arthritis at initial admission, with serology positive for both Mycoplasma pneumonia and Epstein-Barr infection. The patient was discharged without improvement. He was then readmitted with persistence of initial symptoms and, at that stage, he fulfilled the proposed diagnostic criteria of AOSD. The purpose of this case report is to describe the triggering infections that can initially mislead diagnosis and to review the literature about AOSD from a primary care perspective. Case PresentationAn 18-year-old African-American man presented to the emergency department with complaints of having had sore throat, joint pain, and a spiking fever for 5 days. The rest of the review of the systems was negative. He had no significant medical history, was not taking any medication, and had no significant family history. He smoked marijuana approximately 2 to 3 times a week. Vital signs at admission were a temperature of 38.8°C, heart rate of 92 beats per minute, respiratory rate of 20 breaths per minute, and blood pressure of 126/74 mm Hg. Physical examination showed shotty cervical lymphadenopathy bilaterally. Cardiovascular and respiratory systems were normal. The abdominal examination showed mild hepatosplenomegaly and the genitourinary examination was normal. A moderate left knee joint effusion was noted, and tenderness was elicited in the shoulder, knee, elbow and wrist joints. Total white blood cell count, bands, C-reactive protein level, erythrocyte sedimentation rate (ESR), and liver function test were elevated. See Table 1 for further details about the laboratory results of the patient during the initial admission.Transthoracic echocardiogram revealed a small pericardial effusion, with no valve vegetation. A chest radiograph showed a left lower lobe consolidation with minimal pleural effusion. Radiographs of the left knee revealed a moderate effusion. Left knee joint fluid study was normal. Urinalysis, urine culture, and 3 sets of blood cultures were negative. Based on the chest radiograph findings and increased white blood cell count, a diagnosis of community-acquired pneumonia was made and the patient was started on ceftriaxone and azithromycin. Mycoplasma and Epstein-Barr virus serologies This article was externally peer reviewed.

IntroductionPacemaker induced superior vena cava syndrome is an unusual complication of pacemaker implantation. Endothelial damage caused by repeated trauma from the lead is thought to be responsible for the stenosis. Malignancy has been historically the most common etiology. However, the increase in use of indwelling venous catheters and cardiac pacemaker has resulted in more patients with superior vena cava syndrome of benign etiology.Case presentationA 54-year-old female presented with recurrent spasm and swelling of the neck for the duration of two months. Pacemaker was implanted in 1997 for symptomatic third degree heart block. It was removed in 2007 due to recurrent infection at the lead site. Computed tomography of the chest and venogram were performed which showed stenosis at origin of the superior vena cava with some collateral circulation. She underwent angioplasty by the interventional radiology and is currently free of symptoms.ConclusionsOur case highlights a relatively uncommon complication of pacemaker. As a primary care physician, one should be aware of this unusual complication of pacemaker. Superior vena cava syndrome should be suspected in patients with history of pacemaker insertion who present to the primary care physician with neck spasm or neck swelling. Primary care physicians should also be aware balloon angioplasty is a reasonable primary intervention in selected patient population.

Shared medical appointments, which allow greater access to care and provide peer support, may be an effective treatment modality for prediabetes. We used a retrospective propensity-matched cohort analysis to compare patients attending a prediabetes shared medical appointment to usual care. Primary outcome was patient's weight change over 24 months. Secondary outcomes included change in hemoglobin A 1c , low density lipoprotein, and systolic blood pressure. The shared medical appointments group lost more weight (2.88 kg vs 1.29 kg, P = .003), and achieved greater reduction in hemoglobin A 1c (−0.87% vs +0.87%, P = .001) and systolic blood pressure (−4.35 mmHg vs +0.52 mmHg, P = .044). The shared medical appointment model can be effective in treating prediabetes.