We report a case of a 31 year old male with extensive subclinical sinusitis leading to erosion in the cribriform plate and subsequent meningitis caused by the organism Moraxella osloensis. The patient presented to the emergency department with rapid onset confusion, neck stiffness and headache. Inflammatory markers, renal and liver function, and a chest radiograph were all normal. CT Head showed extensive polyp disease in the paranasal sinuses with expansion of the left frontal sinus and CT Sinuses revealed an area of low attenuation in the cribriform plate consistent with bony erosion. MRI Head showed thick loculated sinus inflammation. Lumbar puncture yielded CSF with a high white cell count of predominantly mononuclear cells, no visible organisms and an elevated protein. CSF microscopy, culture and viral PCR were not diagnostic, and so the CSF was sent for 16S rDNA PCR screening, which identified the rDNA of Moraxella osloensis. Moraxella osloensis is a rare cause of bacterial meningitis, with only a few reported cases. This case illustrates that sinusitis, while a common condition, when severe can predispose to intracranial infection with atypical and low virulence organisms such as Moraxella species, which do not commonly cause invasive CNS disease. This case represents the first case of Moraxella osloensis meningitis reported from the United Kingdom.

Waldenström macroglobulinemia (WM) is a rare, incurable low grade lymphoma following a relapsing trajectory. Management strategies have evolved with the introduction of targeted therapy including new classes of Bruton tyrosine kinase inhibitor (BTKi). Treatment may however be limited particularly at relapse by a lack of drug availability and tolerability. We assessed the real-world efficacy and tolerability of bortezomib-containing regimens in patients with WM at frontline and relapse including those with prior BTKi resistance. Forty-one patients were identified with 44 bortezomib-containing regimens administered (n = 12 frontline, n = 32 relapse). Of patients treated at relapse, the median prior lines of therapy was 3 (range 1-7). 24% (10/41) of the cohort were refractory or intolerant to BTKi prior to bortezomib delivery. The median follow-up after bortezomib administration was 34 months (range 0-131). Overall response rate was 88%; 2-year overall survival and progression-free survival were 90% (95% confidence interval [CI] 73-96) and 76% (95% CI 55-87), respectively. Median time-to-next-treatment was 66 months. Neuropathy (grade 1-2) occurred in 24% (8/34) and did not result in treatment cessation in any case. Gastrointestinal disturbance occurred in 7% (3/41). Treatment discontinuations were rare (1/44; 2%), suggesting a manageable safety profile. Major response rate was comparable in those with prior BTKi compared with those without (75% [6/8] vs 84% [27/32], p = 0.61). Bortezomib should be considered as a treatment modality particularly in those who are refractory to BTKi.

Allergic Rhinitis refers to immunoglobulin E mediated inflammation of the nasal cavity. Mast cell activation releases histamine, the inflammatory mediator that plays a central role in the biochemical mechanism of this disease. It is metabolised by Diamine Oxidase (DAO) and Histamine N-methyltransferase (HNMT). In this randomised open label study, we recruited 60 patients out of which 30 patients were provided standard treatment and 30 were provided standard treatment along with instructions for dietary modification. The dietary modification consisted of excluding commonly consumed histamine-rich foods and foods containing pro-histamine or anti-DAO active constituents. Each patient was followed up 3 times over the course of 15 days. The patients in the dietary modification group showed significant improvement in rhinitis symptoms within 7 days, while the control group’s improvement was not significant in the same amount of time. The overall improvement between the first and last visits was more significant in the dietary modification group as compared to the control group. Thus, the exclusion of histamine-rich foods and foods containing pro-histamine or anti-DAO compounds may be recommended to patients of allergic rhinitis for quicker and better recovery. This approach may also be explored in other conditions where histamine is implicated such as asthma and infections caused by coronaviruses.

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