and an unrecordable blood pressure. A second central venous catheter was therefore inserted exclusively for infusion of dopamine. Four days after her admission the infusion was successfully stopped. She was eventually discharged from hospital having made a complete recovery. DiscussionThis patient had streptococcal cellulitis that caused circulatory and respiratory failure masquerading as venous thrombosis and pulmonary embolism. Streptococcal infection may be rapidly progressive and fatal despite treatment with antibiotics, and seven out of eight patients reported on recently died.' 2 In our patient antibiotics would not have influenced the outcome without early intensive supportive measures, including full haemodynamic monitoring. In particular, we were impressed by the extreme dependence of her condition on dopamine.The existence of a factor that acts as a myocardial depressant and contributes to shock in cases of severe sepsis has previously been postulated.3 Although thermodilution studies to measure cardiac output were not performed in this patient, we believe that the rapidity of onset and degree of hypotension together with the bradycardia that occurred when the dopamine infusion was interrupted strongly suggest the presence of such a humoral factor in our case. Effect of prenalterol on orthostatic hypotension in the Shy-Drager syndrome J GOOVAERTS, C VERFAILLIE, R FAGARD, D KNOCKAERT Abstract Treatment of idiopathic orthostatic hypotension is often unsatisfactory. A patient with the Shy-Drager syndrome, in which the most important symptom is orthostatic hypotension, was treated with prenalterol, initially 30 mg six times daily. The dosage was reduced to 30 mg four times daily because of the development of complex ventricular premature beats. Orthostatic symptoms were reduced and standing blood pressure increased. Fludrocortisone 0 5 mg a day was added to treatment with further improvement. This clinical effect was maintained throughout 12 months of follow up, during which the treatment was continued unchanged. Prenalterol was effective in reducing orthostatic symptoms in this patient. Further studies in patients with a similar haemodynamic pattern are indicated.

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We report a case of a 43-year-old male with a history of migraine with aura and a heterozygous factor V Leiden deficiency presenting with a complicated paradoxical arterial embolism of a deep vein thrombosis via a patent foramen ovale (PFO). Recovery was complicated with a dropfoot due to a reperfusion compartment syndrome. Treatment involved a multidisciplinary approach including embolectomy, fasciotomy, percutaneous PFO closure and extensive rehabilitation. At 5-month follow-up, the patient reported significant improvement in pain, sensation, strength and function of his leg. Repeat electromyography showed reinnervation potentials and improvement of maximal contraction in muscles innervated by the tibial and peroneal nerve, where the latter was not fully restored; however, the patient was able to walk independently again without orthosis and had restarted working. In conclusion, a complicated paradoxical embolism should be treated in a multidisciplinary setting to optimize diagnostic approach, treatment and rehabilitation.