Coronavirus disease 2019 (COVID-19) is a novel infection of which we still have much to learn. Microvascular and macrovascular complications are increasingly recognised as being among the drivers of morbidity and mortality in patients with this condition. Here we present a case of a woman with COVID-19 who suffered massive and bilateral middle cerebral artery strokes, which presented as reduced consciousness several days into admission. Clinicians need to be aware of possible causes of reduced consciousness in COVID-19 patients, particularly as delirium appears to be a common complication, and revisit working diagnoses if the clinical picture does not fully fit. Studies into both anticoagulation and the management of stroke in the context of COVID-19 are urgently needed to help inform future practice.

Introduction The nuc gene encodes a thermonuclease which is present in Staphylococcus aureus but not in coagulase-negative staphylococci (CoNS) and is the target of the rapid phenotypic thermonuclease test. The effect of nuc gene variation in methicillin-resistant S. aureus (MRSA) on the performance of PCR testing has been noted, although there are no reports about the effect of MRSA on the activity of the thermonuclease enzyme. Aim Our goals were to examine the sensitivity and specificity of the thermonuclease test used to distinguish S. aureus from CoNS cultured from blood. In addition, we aimed to assess differences in the sensitivity, specificity and accuracy of the thermonuclease test between methicillin-sensitive S. aureus (MSSA) and MRSA isolates. Methodology We performed a retrospective analysis of 1404 isolates. Each isolate from a positive blood culture was identified as a Gram-positive coccus by microscopy then analysed with the thermonuclease test (Southern Group Laboratory) prior to confirmatory identification using VITEK microbial identification platforms (bioMérieux) and cefoxitin disc diffusion testing. Results Of 1331 samples included in the final analysis, 189 were thermonuclease-positive, of which 176 were identified as S. aureus . Of the 1142 thermonuclease-negative samples, 13 were finally identified as S. aureus , giving a sensitivity of 93.1 % (95 % confidence interval [CI] 88.5–96.3) and specificity of 98.9 % (95 % CI 98.1–99.4). Of the nine proven MRSA samples, eight were thermonuclease-positive, giving a sensitivity of 88.9 % (95 % CI 51.8–99.7). Thermonuclease test accuracy for MSSA and MRSA isolates was 98.1 % (95 % CI 97.2–98.8) versus 98.8 % (95 % CI 98.0–99.3), respectively. Conclusions In the era of increasing use of molecular-based microbiology assays, the thermonuclease test remains a simple, inexpensive and robust test for the presumptive identification of S. aureus cultured from blood, irrespective of methicillin sensitivity.

Malignant mesotheliomas (MMs) are malignancies of the mesothelium, with primary deposits originating in the pleura, peritoneum, pericardium and the tunica vaginalis (ie, testicular). Metastatic spread is commonly reported to affect the liver, adrenal glands, kidney and contralateral lung (in cases of malignant pleural mesothelioma). Metastases to distant sites are uncommon. Spread to the oral cavity in particular is very rare. A total of 23 cases of metastatic spread to the oral cavity have been reported in the literature to date; of those, 9 cases have been to the tongue. Given the rarity of the site of metastasis, the management remains challenging. This case highlights a rare site of metastasis in MM, discusses treatment options available and briefly talks about technical limitations in treating a mobile structure such as the tongue. Good palliative and supportive care is crucial in managing cases where no curative treatment is possible.