In October 1990 there was a severe outbreak of Escherichia coli O157 in two psychogeriatric wards of a large psychiatric hospital in Lanarkshire. There were 11 cases (eight patients and three staff), of whom four died (all patients). Two cases, one staff and one patient (the likely index case) were identified serologically after the outbreak was over. E. coli O157 was not cultured from any food, water or milk samples, and the evidence suggests that the index case had eaten food brought into the hospital. The results also suggest that the incubation period of the organism may be longer than is currently recognized, particularly for person-to-person spread. A Fatal Accident Inquiry was held into the deaths, and the Sheriff's Determination is discussed together with the implications of the results for infection control procedures.

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A 20-year-old woman was admitted with pedal edema, facial puffiness of 5-6 months duration, along with additional complaints of alopecia, oral ulcers, and photosensitivity. There was no arthralgia/ arthritis or Raynaud's phenomenon. On clinical examination and laboratory investigations, she was found to be anemic (Hb-6.8 mg/ dL) with pancytopenia (TLC-2,800/μL, platelet count-119,000/ μL). She was having nephrotic range proteinuria (24-hour urinary protein-3.2 g/TV) and mild renal dysfunction (S. creatinine-1.3 mg/dL). Her serum complement (C3/C4) was low. Based on the above findings, a diagnosis of systemic lupus erythematosus (SLE) was made with hematological and renal involvement. This was further supported by positive ANA and dsDNA titers. Her pANCA was also positive. Hence, a renal biopsy was performed for histopathological examination which confirmed the presence of crescentic glomerulonephritis due to lupus nephritis (LN) (class IV) along with thrombotic microangiopathy (TMA). She was given MP pulses and oral steroids (1 mg/kg/day). Cell counts improved after steroid treatment. Thereafter, a monthly cyclophosphamide pulse was given according to NIH protocol with oral steroids. Two weeks later, she complained of depressive symptoms. Her renal function deteriorated with rising serum creatinine (4.8 mg/dL) and blood urea (116). Her platelet count dropped to 78,000/mL and serum LDH was high (2,200 IU/L). A possibility of TTP/CNS lupus was considered. She was managed with anti-depressants, seven sessions of plasma exchange, and another dose of endoxan in view of worsening of disease activity. Neuropsychiatric symptoms improved and serum creatinine came down to 3.3 mg/dL. However, after a few days, she became febrile with pain and swelling of the left thigh, decreased oral intake, and irritability. A possibility of left thigh cellulitis was considered and managed with piperacillin and tazobactam in emergency OPD. She subsequently became afebrile with a reduction in redness and swelling. Despite this, she remained irritable and had decreased oral intake. Thus, she was readmitted for the third time.

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